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Ragoonanan D, Nickelsen P, Tran N, Allen B, Emborski R, Legare A, Villela A, Hampson L, Busey K, Shomo E, Broomfield A, Hailu K. Vasopressin Initiation as a Second-Line Vaso Pressor in Early Septic Shock (VISPSS). J Intensive Care Med 2024; 39:306-312. [PMID: 37715634 DOI: 10.1177/08850666231201364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/18/2023]
Abstract
BACKGROUND Vasopressin is recommended as a second-line vasoactive agent for the management of septic shock; however, a paucity of data to guide its optimal use remains. The aim was to evaluate the effect of time-to vasopressin initiation and norepinephrine (NE) dose at vasopressin initiation on clinical outcomes in patients presenting with septic shock. METHODS This was a multi-centered, retrospective, observational study conducted in patients with septic shock. Patients were divided into 2 groups: patients initiated on vasopressin when NE-equivalent dose (NEE) < 0.25 mcg/kg/min or ≥ 0.25 mcg/kg/min. The primary outcome was time-to-vasopressor discontinuation (hours). Secondary outcomes included 28-day in-hospital mortality, intensive care unit (ICU) length of stay (LOS), fluid balance after 72 hours, and the change in NEE at 12 hours. RESULTS A total of 302 patients were included in this study. After propensity-score matching, 73 patients in each group were identified for analysis. There was no significant difference in the time-to-vasopressor discontinuation (hours) between the groups (88.8 [55-187.5] vs 86.7 [47-172]); p = 0.7815). Fluid balance (mL) at 72 hours was significantly lower when vasopressin was initiated at NEE < 0.25 mcg/kg/min (1769 [71-7287] vs 5762 [1463-8813]; p = 0.0077). A multivariable linear regression showed shorter time to shock resolution with earlier vasopressin initiation, defined as within 4 hours (p < 0.05). CONCLUSION In this propensity-score matched cohort, vasopressin initiation at NEE < 0.25 mcg/kg/min was not associated with shorter vasopressor duration. There was a lower fluid balance at 72 hours when vasopressin was initiated at lower NE doses.
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Affiliation(s)
- David Ragoonanan
- Department of Pharmacy Services, Sarasota Memorial Hospital, Sarasota, FL, USA
| | - Paige Nickelsen
- Department of Pharmacy Services, University of California San Diego, San Diego, CA, USA
| | - Nicolas Tran
- Department of Pharmacy Services, Tampa General Hospital, Tampa, FL, USA
| | - Bryan Allen
- Department of Pharmacy Services, Ascension St. Vincent's, Jacksonville, FL, USA
| | - Rebecca Emborski
- Department of Pharmacy Services, Sarasota Memorial Hospital, Sarasota, FL, USA
| | - Anit Legare
- Department of Pharmacy Services, Sarasota Memorial Hospital, Sarasota, FL, USA
| | - Antonia Villela
- Department of Pharmacy Services, Sarasota Memorial Hospital, Sarasota, FL, USA
| | - Lauryn Hampson
- Department of Pharmacy Services, Sarasota Memorial Hospital, Sarasota, FL, USA
| | - Kirsten Busey
- Department of Pharmacy Services, Sarasota Memorial Hospital, Sarasota, FL, USA
| | - Eileen Shomo
- Department of Pharmacy Services, Sarasota Memorial Hospital, Sarasota, FL, USA
| | - Abby Broomfield
- Department of Pharmacy Services, Sarasota Memorial Hospital, Sarasota, FL, USA
| | - Kirubel Hailu
- Department of Pharmacy Services, Ascension St. Vincent's, Jacksonville, FL, USA
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Zhang Y, Wang M, Lu Z, Yang M. Effect of Fluid Resuscitation Strategies for Obese Patients with Sepsis and Septic Shock: A Systematic Review. Intensive Care Res 2023; 3:61-8. [PMID: 36320644 DOI: 10.1007/s44231-022-00019-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 10/17/2022] [Indexed: 11/02/2022]
Abstract
Purpose As the Surviving Sepsis Campaign (2021) recommended, patients with sepsis should be given a liquid infusion of 30 ml/kg (ideal body weight). However, the strategy may result in insufficient resuscitation for obese patients with sepsis. Therefore, we conducted a systematic evaluation of the effectiveness of the initial resuscitation strategy in obese sepsis patients. Materials and methods A computer search of PubMed, Embase, Cochrane library, and other databases collected cohort studies from the beginning of the survey to December 2021 to include articles evaluating initial resuscitation strategies for sepsis-obese patients. Results Of the six studies included, five used ideal body weight infusion strategies, and three used actual body weight infusion strategies. Differences in fluid volume were observed between the two strategies, but no significant difference was observed in the mortality of obese sepsis patients. In addition, there may be an infusion strategy other than the above two infusion methods, and the safety and efficacy of the new infusion strategy are unclear. The obesity paradox has been observed in most infusion strategies. Conclusion The association between obesity and infusion strategy has rarely been investigated in patients with sepsis and septic shock, and the existing results are conflicting. The risk of bias in all included studies was moderate or high. Before providing broad recommendations on the optimal first resuscitation approach to lower the chance of mortality, further clinical trials, and prospective research need to be done.
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Abstract
The prevalence of obesity continues to rise and is caused by many factors. Obesity places patients at risk for high blood pressure, diabetes, heart disease, and cancer. Although obesity in the normal population is associated with increased morbidity and mortality, obesity in critically ill patients has lower mortality. This is referred to as the obesity paradox, and although not fully understood, involves several mechanisms that demonstrate a protective factor in critically ill obese patients. However, despite the benefit, the management of critically ill obese patients faces many challenges.
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Affiliation(s)
- Candice Falls
- University of Kentucky, College of Nursing, 751 Rose Street, Lexington, KY 40536, USA.
| | - Sheila Melander
- University of Kentucky, College of Nursing, 751 Rose Street, Lexington, KY 40536, USA
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Abstract
ABSTRACT We sought to review the pharmacology of vasoactive therapy and fluid administration in sepsis and septic shock, with specific insight into the physiologic interplay of these agents. A PubMed/MEDLINE search was conducted using the following terms (vasopressor OR vasoactive OR inotrope) AND (crystalloid OR colloid OR fluid) AND (sepsis) AND (shock OR septic shock) from 1965 to October 2020. A total of 1,022 citations were reviewed with only relevant clinical data extracted. While physiologic rationale provides a hypothetical foundation for interaction between fluid and vasopressor administration, few studies have sought to evaluate the clinical impact of this synergy. Current guidelines are not in alignment with the data available, which suggests a potential benefit from low-dose fluid administration and early vasopressor exposure. Future data must account for the impact of both of these pharmacotherapies when assessing clinical outcomes and should assess personalization of therapy based on the possible interaction.
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Affiliation(s)
- Brooke Barlow
- Department of Pharmacy, University of Kentucky, Lexington, Kentucky
- College of Pharmacy, Pharmacy Practice and Science, University of Kentucky, Lexington, Kentucky
| | - Brittany D Bissell
- Department of Pharmacy, University of Kentucky, Lexington, Kentucky
- College of Pharmacy, Pharmacy Practice and Science, University of Kentucky, Lexington, Kentucky
- College of Medicine, Pulmonary, Critical Care, and Sleep Medicine, University of Kentucky, Lexington, Kentucky
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Kaseer HS, Patel R, Tucker C, Elie MC, Staley BJ, Tran N, Lemon S. Comparison of fluid resuscitation weight-based dosing strategies in obese patients with severe sepsis. Am J Emerg Med 2021; 49:268-272. [PMID: 34171722 DOI: 10.1016/j.ajem.2021.06.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 06/08/2021] [Accepted: 06/14/2021] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE This study aims to compare the composite outcome of progression to septic shock between 30 mL/kg/ideal body weight (IBW) versus 30 mL/kg/non-IBW fluid resuscitation dosing strategies in obese patients with severe sepsis. METHODS We retrospectively evaluated obese patients admitted to an academic tertiary care center for the management of severe sepsis. Patients were included if they had a fluid bolus order placed using the sepsis order set between Oct 2018 and Sept 2019. The primary objective was the composite of progression to septic shock, defined as either persistent hypotension within 3 h after the conclusion of the 30 mL/kg fluid bolus administration or the initiation of vasopressor(s) within 6 h of the bolus administration. RESULTS Of 72 included patients, 49 (68%) were resuscitated using an IBW-based and 23 (32%) using a non-IBW-based dosing strategy. There were similar rates of progression to septic shock in the IBW and non-IBW groups (18% vs. 26%; p = 0.54). Median ICU and hospital LOS in the IBW group versus non-IBW group were (0 [IQR 0] vs. 0 [IQR 0 to 4] days; p = 0.13) and (6 [IQR 3 to 10] vs. 8 [IQR 5 to 12] days; p = 0.07), respectively. In-hospital mortality rates were similar between the groups. CONCLUSIONS Our study results suggest that in obese septic patients, fluid administration using an IBW-dosing strategy did not affect the progression to septic shock.
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Affiliation(s)
- Haya S Kaseer
- Department of Pharmacy, University of Florida Health Shands Hospital, Gainesville, FL, United States of America.
| | - Rusha Patel
- Department of Pharmacy, University of Florida Health Shands Hospital, Gainesville, FL, United States of America.
| | - Calvin Tucker
- Department of Pharmacy, University of Florida Health Shands Hospital, Gainesville, FL, United States of America.
| | - Marie-Carmelle Elie
- Department of Emergency Medicine, University of Florida Health Shands Hospital, Gainesville, FL, United States of America.
| | - Benjamin J Staley
- Department of Pharmacy, University of Florida Health Shands Hospital, Gainesville, FL, United States of America.
| | - Nicolas Tran
- University of Florida College of Pharmacy, Gainesville, FL, United States of America
| | - Steve Lemon
- Department of Pharmacy, University of Florida Health Shands Hospital, Gainesville, FL, United States of America.
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Hu Y, Zhou J, Cao Q, Wang H, Yang Y, Xiong Y, Zhou Q. Utilization of Echocardiography After Acute Kidney Injury Was Associated with Improved Outcomes in Patients in Intensive Care Unit. Int J Gen Med 2021; 14:2205-2213. [PMID: 34113152 PMCID: PMC8183456 DOI: 10.2147/ijgm.s310445] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 04/30/2021] [Indexed: 12/13/2022] Open
Abstract
Background We aimed to investigate the association between usage of transthoracic echocardiography (TTE) within 24 hours after acute kidney injury (AKI) and the prognosis of patients in intensive care unit (ICU). Methods The Medical Information Mart for Intensive Care III (MIMIC-III) database was used to identify AKI patients with and without TTE administration. The primary outcome was 28-day mortality. Multivariable regression was used to clarify the association between TTE and clinical outcomes and propensity score matching (PSM) and inverse probability of treatment weighting (IPTW) were utilized to validate our findings. Results Among 23,945 eligible AKI patients, 3361 patients who received TTE and 3361 who did not conduct TTE had similar propensity scores which were included in this study. After matching, the TTE group had a significantly lower 28-day mortality (OR 0.80, 95% CI 0.72–0.88, P<0.001). Patients in the TTE group received more fluid on day 1 and day 2 and had a more urine volume on day 1 and day 3, and the reduction in serum creatinine was greater than that in the no TTE group. The mediating effect of creatinine reduction was remarkable for the whole cohort (P=0.02 for the average causal mediation effect). Conclusion TTE utilization was associated with decreased risk-adjusted 28-day mortality for AKI patients in ICU and was proportionally mediated through creatinine reduction.
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Affiliation(s)
- Yugang Hu
- Department of Ultrasound Imaging, Renmin Hospital of Wuhan University, Wuhan, 430061, People's Republic of China
| | - Jia Zhou
- Department of Ultrasound Imaging, Renmin Hospital of Wuhan University, Wuhan, 430061, People's Republic of China
| | - Quan Cao
- Department of Ultrasound Imaging, Renmin Hospital of Wuhan University, Wuhan, 430061, People's Republic of China
| | - Hao Wang
- Department of Ultrasound Imaging, Renmin Hospital of Wuhan University, Wuhan, 430061, People's Republic of China
| | - Yuanting Yang
- Department of Ultrasound Imaging, Renmin Hospital of Wuhan University, Wuhan, 430061, People's Republic of China
| | - Ye Xiong
- Department of Ultrasound Imaging, Renmin Hospital of Wuhan University, Wuhan, 430061, People's Republic of China
| | - Qing Zhou
- Department of Ultrasound Imaging, Renmin Hospital of Wuhan University, Wuhan, 430061, People's Republic of China
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Erstad BL, Barletta JF. Drug dosing in the critically ill obese patient: a focus on medications for hemodynamic support and prophylaxis. Crit Care 2021; 25:77. [PMID: 33622380 PMCID: PMC7901103 DOI: 10.1186/s13054-021-03495-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 02/08/2021] [Indexed: 12/29/2022] Open
Abstract
Medications used for supportive care or prophylaxis constitute a significant portion of drug utilization in the intensive care unit. Evidence-based guidelines are available for many aspects of supportive care but drug doses listed are typically for patients with normal body habitus and not morbid obesity. Failure to account for the pharmacokinetic changes that occur with obesity can lead to an incorrect dose and treatment failure or toxicity. This paper is intended to help clinicians design initial dosing regimens in critically ill obese patients for medications commonly used for hemodynamic support or prophylaxis. A detailed literature search of medications used for supportive care or prophylaxis listed in practice guidelines was conducted with an emphasis on obesity, pharmacokinetics and dosing. Relevant manuscripts were reviewed and strategies for dosing are provided. For medications used for hemodynamic support, a similar strategy can be used as in non-obese patients. Similarly, medications for stress ulcer prophylaxis do not need to be adjusted. Anticoagulants for venous thromboembolism prophylaxis, on the other hand, require an individualized approach where higher doses are necessary.
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Affiliation(s)
- Brian L Erstad
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, 1295 N Martin Ave, PO Box 210202, Tucson, AZ, 85721, USA
| | - Jeffrey F Barletta
- Department of Pharmacy Practice, College of Pharmacy, Midwestern University, 19555 N 59th Ave, Glendale, AZ, 85308, USA.
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Abstract
The prevalence of obesity continues to rise worldwide, and anesthesiologists must be aware of current best practices in the perioperative management of the patient with obesity. Obesity alters anatomy and physiology, which complicates the evaluation and management of obese patients in the perioperative setting. Gastric point-of-care ultrasound (PoCUS) is a noninvasive tool that can be used to assess aspiration risk in the obese patient by evaluating the quantity and quality of gastric contents. An important perioperative goal is adequate end-organ perfusion. Standard noninvasive blood pressure (NIBP) is our best available routine surrogate measurement, but is vulnerable to greater inaccuracy in patients with obesity compared to the nonobese population. Current NIBP methodologies are discussed. Obese patients are at risk for wound and surgical site infections, but few studies conclusively guide the exact dosing of intraoperative prophylactic antibiotics for them. We review evidence for low-molecular-weight heparins and weight-based versus nonweight-based administration of vasoactive medications. Finally, intubation and extubation of the patient with obesity can be complicated, and evidence-based strategies are discussed to mitigate danger during intubation and extubation.
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Affiliation(s)
- Tiffany S Moon
- From the Department of Anesthesiology and Pain, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | | | - Roman Schumann
- Department of Anesthesiology and Perioperative Medicine, Tufts University School of Medicine, Boston, Massachusetts
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9
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Kiracofe-Hoyte BR, Doepker BA, Riha HM, Wilkinson R, Rozycki E, Adkins E, Lehman A, Van Berkel MA. Assessment of fluid resuscitation on time to hemodynamic stability in obese patients with septic shock. J Crit Care 2020; 63:196-201. [PMID: 33012588 DOI: 10.1016/j.jcrc.2020.09.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Revised: 09/03/2020] [Accepted: 09/09/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE Assess time to hemodynamic stability (HDS) in obese patients with septic shock who received <30 vs. ≥30 ml/kg of initial fluid resuscitation based on actual body weight (ABW). MATERIALS AND METHODS Multicenter, retrospective, cohort analysis of 322 patients. RESULTS Overall 216 (67%) patients received <30 ml/kg of initial fluid resuscitation. Initial fluid received was lower in the <30 ml/kg vs. ≥30 ml/kg group (16 vs. 37 ml/kg). The ≥30 ml/kg group had shorter time to HDS (multivariable p = 0.038) and lower riskof in-hospital death (multivariable p = 0.038). An exploratory subgroup analysis (n = 227) was performed, classifying patients by dosing strategy [ABW, adjusted body weight (AdjBW), ideal body weight (IBW)] based on fluid received at 3 h divided by 30 ml/kg. ABW dosed patients had a shorter time to HDS (multivariable p = 0.013) and lower risk of in-hospital death (multivariable p = 0.008) vs. IBW. Similar outcomes were observed between ABW vs. AdjBW. CONCLUSIONS Obese patients given ≥30 ml/kg based on ABW had a shorter time to HDS and a lower risk of in-hospital death. Exploratory results suggest improved outcomes resuscitating by ABW vs. IBW; ABW showed no strong benefit over AdjBW. Further prospective studies are needed to confirm the optimal fluid dosing in obese patients.
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Affiliation(s)
- Brittany R Kiracofe-Hoyte
- Department of Pharmacy, Spectrum Health, 100 Michigan St. NE, Grand Rapids, MI 49503, United States of America.
| | - Bruce A Doepker
- Department of Pharmacy, The Ohio State University Wexner Medical Center, 410 West 10(th) Ave., Columbus, OH 43210, United States of America
| | - Heidi M Riha
- Department of Pharmacy, Ascension St. Elizabeth Hospital, 1506 S Oneida St., Appleton, WI 54915, United States of America
| | - Rachel Wilkinson
- Department of Pharmacy, Fort Sanders Regional Medical Center, 1901 W Clinch Ave., Knoxville, TN 37916, United States of America
| | - Elizabeth Rozycki
- Department of Pharmacy, The Ohio State University Wexner Medical Center, 410 West 10(th) Ave., Columbus, OH 43210, United States of America
| | - Eric Adkins
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, 410 West 10th Ave., Columbus, OH 43210, United States of America
| | - Amy Lehman
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University Wexner Medical Center, 410 West 10th Ave., Columbus, OH 43210, United States of America
| | - Megan A Van Berkel
- Department of Pharmacy, Erlanger Health System, 975 E Third St., Chattanooga, TN 37403, United States of America
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10
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Abstract
The obesity pandemic now affects hundreds of millions of people worldwide. As obesity rates continue to increase, emergency physicians are called on with increasing frequency to resuscitate obese patients. This article discusses important anatomic, physiologic, and practical challenges imposed by obesity on resuscitative care. Impacts on hemodynamic monitoring, airway and ventilator management, and pharmacologic therapy are discussed. Finally, several important clinical scenarios (trauma, cardiac arrest, and sepsis), in which alterations to standard treatments may benefit obese patients, are highlighted.
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Affiliation(s)
- Sara Manning
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA.
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11
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Vincent JL, Jones G, David S, Olariu E, Cadwell KK. Frequency and mortality of septic shock in Europe and North America: a systematic review and meta-analysis. Crit Care 2019; 23:196. [PMID: 31151462 DOI: 10.1186/s13054-019-2478-6] [Citation(s) in RCA: 213] [Impact Index Per Article: 42.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 05/15/2019] [Indexed: 12/20/2022]
Abstract
Background Septic shock is the most severe form of sepsis, in which profound underlying abnormalities in circulatory and cellular/metabolic parameters lead to substantially increased mortality. A clear understanding and up-to-date assessment of the burden and epidemiology of septic shock are needed to help guide resource allocation and thus ultimately improve patient care. The aim of this systematic review and meta-analysis was therefore to provide a recent evaluation of the frequency of septic shock in intensive care units (ICUs) and associated ICU and hospital mortality. Methods We searched MEDLINE, Embase, and the Cochrane Library from 1 January 2005 to 20 February 2018 for observational studies that reported on the frequency and mortality of septic shock. Four reviewers independently selected studies and extracted data. Disagreements were resolved via consensus. Random effects meta-analyses were performed to estimate pooled frequency of septic shock diagnosed at admission and during the ICU stay and to estimate septic shock mortality in the ICU, hospital, and at 28 or 30 days. Results The literature search identified 6291 records of which 71 articles met the inclusion criteria. The frequency of septic shock was estimated at 10.4% (95% CI 5.9 to 16.1%) in studies reporting values for patients diagnosed at ICU admission and at 8.3% (95% CI 6.1 to 10.7%) in studies reporting values for patients diagnosed at any time during the ICU stay. ICU mortality was 37.3% (95% CI 31.5 to 43.5%), hospital mortality 39.0% (95% CI 34.4 to 43.9%), and 28-/30-day mortality 36.7% (95% CI 32.8 to 40.8%). Significant between-study heterogeneity was observed. Conclusions Our literature review reaffirms the continued common occurrence of septic shock and estimates a high mortality of around 38%. The high level of heterogeneity observed in this review may be driven by variability in defining and applying the diagnostic criteria, as well as differences in treatment and care across settings and countries. Electronic supplementary material The online version of this article (10.1186/s13054-019-2478-6) contains supplementary material, which is available to authorized users.
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12
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Farhat A, Grigorian A, Nguyen NT, Smith B, Williams BJ, Schubl SD, Joe V, Elfenbein D, Nahmias J. Obese trauma patients have increased need for dialysis. Eur J Trauma Emerg Surg 2019; 46:1327-1334. [PMID: 31111163 DOI: 10.1007/s00068-019-01147-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 05/11/2019] [Indexed: 12/23/2022]
Abstract
PURPOSE Obesity is a risk factor for the development of acute kidney injury but its effect on the need for dialysis in trauma has not been elucidated. Additionally, the contribution that obesity has towards risk of mortality in trauma is unclear. We hypothesized that patients with a higher body mass index (BMI) will have a higher risk for need of dialysis and mortality after trauma. METHODS This is a retrospective analysis using the National Trauma Data Bank. All patients ≥ 8 years old were grouped based on BMI: normal (18.5-24.99 kg/m2), obese (30-34.99 kg/m2), severely obese (35-39.99 kg/m2) and morbidly obese (≥ 40 kg/m2). The primary outcome was hemodialysis initiation. The secondary outcome was mortality during the index hospitalization. RESULTS From 988,988 trauma patients, 571,507 (57.8%) had a normal BMI, 233,340 (23.6%) were obese, 94,708 (9.6%) were severely obese, and 89,433 (9.0%) were morbidly obese. The overall rate of hemodialysis was 0.3%. After adjusting for covariates, we found that obese (OR 1.36, CI 1.22-1.52, p < 0.001), severely obese (OR 1.89, CI 1.66-2.15, p < 0.001) and morbidly obese (OR 2.04, CI 1.82-2.29, p < 0.001) patients had a stepwise increased need for hemodialysis after trauma. Obese patients had decreased (OR 0.92, CI 0.88-0.95, p < 0.001), severely obese had similar (OR 1.02, CI 0.97-1.08, p = 0.50) and morbidly obese patients had increased (OR 1.06, CI 1.01-1.12, p = 0.011) risk of mortality after trauma. CONCLUSIONS Obesity was associated with an increased risk for dialysis after trauma. Mortality risk was reduced in obese, similar in severely obese, and increased in morbidly obese trauma patients suggesting an inflection threshold BMI for risk of mortality in trauma.
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Affiliation(s)
- Ahmed Farhat
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine Medical Center, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA.
| | - Areg Grigorian
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine Medical Center, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA
| | - Ninh T Nguyen
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine Medical Center, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA
| | - Brian Smith
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine Medical Center, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA
| | - Barbara J Williams
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine Medical Center, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA
| | - Sebastian D Schubl
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine Medical Center, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA
| | - Victor Joe
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine Medical Center, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA
| | - Dawn Elfenbein
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine Medical Center, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA
| | - Jeffry Nahmias
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine Medical Center, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA
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13
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Schetz M, De Jong A, Deane AM, Druml W, Hemelaar P, Pelosi P, Pickkers P, Reintam-Blaser A, Roberts J, Sakr Y, Jaber S. Obesity in the critically ill: a narrative review. Intensive Care Med 2019; 45:757-769. [PMID: 30888440 DOI: 10.1007/s00134-019-05594-1] [Citation(s) in RCA: 229] [Impact Index Per Article: 45.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 03/05/2019] [Indexed: 11/24/2022]
Abstract
The World Health Organization defines overweight and obesity as the condition where excess or abnormal fat accumulation increases risks to health. The prevalence of obesity is increasing worldwide and is around 20% in ICU patients. Adipose tissue is highly metabolically active, and especially visceral adipose tissue has a deleterious adipocyte secretory profile resulting in insulin resistance and a chronic low-grade inflammatory and procoagulant state. Obesity is strongly linked with chronic diseases such as type 2 diabetes, hypertension, cardiovascular diseases, dyslipidemia, non-alcoholic fatty liver disease, chronic kidney disease, obstructive sleep apnea and hypoventilation syndrome, mood disorders and physical disabilities. In hospitalized and ICU patients and in patients with chronic illnesses, a J-shaped relationship between BMI and mortality has been demonstrated, with overweight and moderate obesity being protective compared with a normal BMI or more severe obesity (the still debated and incompletely understood "obesity paradox"). Despite this protective effect regarding mortality, in the setting of critical illness morbidity is adversely affected with increased risk of respiratory and cardiovascular complications, requiring adapted management. Obesity is associated with increased risk of AKI and infection, may require adapted drug dosing and nutrition and is associated with diagnostic and logistic challenges. In addition, negative attitudes toward obese patients (the social stigma of obesity) affect both health care workers and patients.
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Affiliation(s)
- Miet Schetz
- Division of Cellular and Molecular Medicine, Clinical Department and Laboratory of Intensive Care Medicine, KU Leuven University, Herestraat 49, 3000, Leuven, Belgium.
| | - Audrey De Jong
- Anesthesia and Critical Care Department (DAR-B), Saint Eloi, University of Montpellier, Research Unit: PhyMedExp, INSERM U-1046, CNRS, 34295, Montpellier Cedex 5, France
| | - Adam M Deane
- Department of Medicine and Radiology, Melbourne Medical School, Royal Melbourne Hospital, The University of Melbourne, Parkville, VIC, Australia.,Department of Medicine (Royal Melbourne Hospital), University of Melbourne, Parkville, VIC, Australia
| | - Wilfried Druml
- Klinik für Innere Medizin III, Abteilung für Nephrologie, Allgemeines Krankenhaus Wien, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Pleun Hemelaar
- Department of Intensive Care Medicine (710), Radboud University Medical Centre, Geert Grooteplein Zuid 10, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy.,Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Genoa, Italy
| | - Peter Pickkers
- Department of Intensive Care Medicine (710), Radboud University Medical Centre, Geert Grooteplein Zuid 10, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.,Radboud Center for Infectious Diseases, Nijmegen, The Netherlands
| | - Annika Reintam-Blaser
- Department of Intensive Care Medicine, Lucerne Cantonal Hospital, Lucerne, Switzerland.,Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia
| | - Jason Roberts
- University of Queensland Centre for Clinical Research, Faculty of Medicine, University of Queensland, Herston, Australia.,Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Woolloongabba, Australia.,Pharmacy Department, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Departments of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Yasser Sakr
- Department of Anesthesiology and Intensive Care, Uniklinikum Jena, Jena, Germany
| | - Samir Jaber
- Anesthesia and Critical Care Department (DAR-B), Saint Eloi, University of Montpellier, Research Unit: PhyMedExp, INSERM U-1046, CNRS, 34295, Montpellier Cedex 5, France
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14
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Kotecha AA, Vallabhajosyula S, Apala DR, Frazee E, Iyer VN. Clinical Outcomes of Weight-Based Norepinephrine Dosing in Underweight and Morbidly Obese Patients: A Propensity-Matched Analysis. J Intensive Care Med 2018; 35:554-561. [PMID: 29628015 DOI: 10.1177/0885066618768180] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Weight-based dosing strategy for norepinephrine in septic shock patients with extremes of body mass index has been lesser studied. METHODS This historical study of adult septic shock patients was conducted from January 1, 2010, to December 31, 2015, at all intensive care units (ICUs) in Mayo Clinic, Rochester. Patients with documented body mass index were classified into underweight (body mass index <18.5 kg/m2), normal weight (18.5-24.9 kg/m2), and morbidly obese (≥40 kg/m2) patients. Patients with repeat ICU admissions, ICU stay <1 day, and body mass index 25 to 39.9 kg/m2 were excluded. The primary outcome was in-hospital mortality, and secondary outcomes included cumulative norepinephrine exposure acute kidney injury, cardiac arrhythmias, and 1-year mortality. Two-tailed P < .05 was considered statistically significant. RESULTS From 2010 to 2015, 2016 patients met inclusion-145, 1406, and 466 patients, respectively, in underweight, normal weight, and morbidly obese cohorts. Underweight patients used the highest peak dose and absolute exposure was greatest for morbidly obese patients. In-hospital mortality decreased with increasing log10 body mass index: 41.4% (underweight), 28.4% (normal weight), and 24.7% (morbidly obese), respectively (P < .001); however, this relationship was not noted at 1 year. Unadjusted log10 norepinephrine cumulative exposure (mg) was associated with higher in-hospital mortality, acute kidney injury, cardiac arrhythmias, and 1-year mortality. After adjustment for demographics, body mass index, comorbidity, and illness severity, log10 norepinephrine exposure was an independent predictor of in-hospital mortality (odds ratio 2.4 [95% confidence interval, 2.0-2.8]; P < .001) and 1-year mortality (odds ratio 1.7 [95% confidence interval, 1.5-2.0]; P < .001). In a propensity-matched analysis of 1140 patients, log10 norepinephrine was an independent predictor of in-hospital mortality (odds ratio 2.2 [95% confidence interval, 1.8-2.6]; P < .001). CONCLUSIONS Morbidly obese patients had lower in-hospital mortality but had higher 1-year mortality compared to normal weight and underweight patients. Cumulative norepinephrine exposure was highest in morbidly obese patients. Total norepinephrine exposure was an independent mortality predictor in septic shock.
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Affiliation(s)
- Aditya A Kotecha
- Department of Medicine, Detroit Medical Center/Wayne State University, Detroit, MI, USA.,Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC) Laboratory, Mayo Clinic, Rochester, MN, USA
| | - Saraschandra Vallabhajosyula
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC) Laboratory, Mayo Clinic, Rochester, MN, USA.,Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Dinesh R Apala
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC) Laboratory, Mayo Clinic, Rochester, MN, USA.,Department of Medicine, Creighton University School of Medicine, Omaha, NE, USA
| | - Erin Frazee
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC) Laboratory, Mayo Clinic, Rochester, MN, USA.,Department of Pharmacy, Mayo Clinic, Rochester, MN, USA
| | - Vivek N Iyer
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC) Laboratory, Mayo Clinic, Rochester, MN, USA.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
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15
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Taylor SP, Karvetski CH, Templin MA, Heffner AC, Taylor BT. Initial fluid resuscitation following adjusted body weight dosing is associated with improved mortality in obese patients with suspected septic shock. J Crit Care 2018; 43:7-12. [DOI: 10.1016/j.jcrc.2017.08.025] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 07/14/2017] [Accepted: 08/15/2017] [Indexed: 01/12/2023]
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16
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Zhou X, Ding B, Ye Y, Tang G, Zhang Z. An appropriate mean arterial pressure (MAP) does not always mean hemodynamic stability in septic shock patients. J Crit Care 2018; 43:397-8. [PMID: 29050861 DOI: 10.1016/j.jcrc.2017.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Accepted: 10/03/2017] [Indexed: 11/23/2022]
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