Pharmacologic issues in the management of septic shock

Update on Vasopressors and Inotropes in Septic Shock

Vasopressors and inotropes are used in septic shock in patients who remain hypotensive despite adequate fluid resuscitation. The goal is to increase blood pressure to optimize perfusion to organs. Generally, goal-directed therapy to supra-normal oxygen transport variables cannot be recommended due to lack of benefit. Traditionally, vasopressors and inotropes in septic shock have been started in a step-wise fashion starting with dopamine. Recent data suggest that there may be true differences among vasopressors and inotropes on local tissue perfusion as measured by regional hemodynamic and oxygen transport. When started early in septic shock, norepinephrine decreases mortality, optimizes hemodynamic variables, and improves systemic and regional (eg, renal, gastric mucosal, splanchnic) perfusion. Epinephrine causes a greater increase in cardiac index (CI) and oxygen delivery (DO2 ) and increases gastric mucosal flow, but increases lactic acid and may not adequately preserve splanchnic circulation owing to its predominant vasoconstrictive alpha (α ) effects. Epinephrine may be particularly useful when used earlier in the course of septic shock in young patients and those who do not have any known cardiac abnormalities. Unlike epinephrine, dopamine does not preferentially increase the proportion of CI that preferentially goes to the splanchnic circulation. Dopamine is further limited because it cannot increase CI by more than 35% and is accompanied by tachycardia or tachydysrhythmias. Dopamine, as opposed to norepinephrine, may worsen splanchnic oxygen consumption (VO2 ) and oxygen extraction ratio (O2 ER). Low-dose dopamine has not been shown to consistently increase the glomerular filtration rate or prevent renal failure, and, indeed, worsens splanchnic tissue oxygen use. Routine use of concurrently administered dopamine with vasopressors is not recommended. Phenylephrine should be used when a pure vasoconstrictor is desired in patients who may not require or do not tolerate the beta (β ) effects of dopamine or norepinephrine with or without dobutamine. Patients with high filling pressure and hypotension may benefit from the combination of phenylephrine and dobutamine. Investigational approaches to vasopressor-refractory hypotension in septic shock include the use of vasopressin and corticosteroids.

The systemic inflammatory response syndrome

The systemic inflammatory response syndrome (SIRS) describes the clinical presentation of patients with systemic activation of the inflammatory response from any underlying cause. SIRS is a common problem in acute medical and surgical practice and an important cause of morbidity and mortality. As a consequence of SIRS, patients may develop multiple organ dysfunction syndrome and acute respiratory distress syndrome (ARDS). Over the recent years our understanding of the inflammatory response in SIRS has increased, but as yet specific immunomodulatory therapies have not proved useful. The mainstay of treatment for patients with SIRS and ARDS remains a general supportive care. It is in this area that more encouraging advances are being made, particularly in the management of invasive ventilation and nutrition. In this review we summarize the definitions, epidemiology and pathophysiology of SIRS, ARDS and related conditions. We then give a description of the clinical consequences and treatment of SIRS and ARDS with an emphasis on current aspects of supportive care.

Differing effects of epinephrine, norepinephrine, and vasopressin on survival in a canine model of septic shock

During sepsis, limited data on the survival effects of vasopressors are available to guide therapy. Therefore, we compared the effects of three vasopressors on survival in a canine septic shock model. Seventy-eight awake dogs infected with differing doses of intraperitoneal Escherichia coli to produce increasing mortality were randomized to receive epinephrine (0.2, 0.8, or 2.0 μg·kg−1·min−1), norepinephrine (0.2, 1.0, or 2.0 μg·kg−1·min−1), vasopressin (0.01 or 0.04 U/min), or placebo in addition to antibiotics and fluids. Serial hemodynamic and biochemical variables were measured. Increasing doses of bacteria caused progressively greater decreases in survival ( P < 0.06), mean arterial pressure (MAP) ( P < 0.05), cardiac index (CI) ( P < 0.02), and ejection fraction (EF) ( P = 0.02). The effects of epinephrine on survival were significantly different from those of norepinephrine and vasopressin ( P = 0.03). Epinephrine had a harmful effect on survival that was significantly related to drug dose ( P = 0.02) but not bacterial dose. Norepinephrine and vasopressin had beneficial effects on survival that were similar at all drug and bacteria doses. Compared with concurrent infected controls, epinephrine caused greater decreases in CI, EF, and pH, and greater increases in systemic vascular resistance and serum creatinine than norepinephrine and vasopressin. These epinephrine-induced changes were significantly related to the dose of epinephrine administered. In this study, the effects of vasopressors were independent of severity of infection but dependent on the type and dose of vasopressor used. Epinephrine adversely affected organ function, systemic perfusion, and survival compared with norepinephrine and vasopressin. In the ranges studied, norepinephrine and vasopressin have more favorable risk-benefit profiles than epinephrine during sepsis.

Reduced tissue immigration of monocytes by neuropeptide Y during endotoxemia is associated with Y2 receptor activation

Neuropeptide Y (NPY) increases survival in experimental septic shock, which might be mediated by cardiovascular and/or immunological effects. To study the latter hypothesis, we monitored blood leukocyte subsets over 96 h after intravenous (i.v.) application of LPS in chronically i.v.-cannulated rats. LPS induced a dramatic leukopenia at 4 h after challenge, which was blunted in NPY-treated animals by stabilizing granulocyte and T-lymphocyte numbers. In addition, NPY treatment prevented tissue immigration of monocytes at early time points and consecutively mobilized activated monocytes from the third day after challenge. RT-PCR and in vitro adhesion studies provided evidence for a NPY Y2 receptor-mediated effect on monocytes. Thus, NPY treatment has profound receptor-specific effects on the migration and adhesion of leukocytes under endotoxemic conditions.

The role of the critical care nurse in the assessment and management of the patient with severe sepsis

Sepsis with acute organ dysfunction is common, frequently fatal, and expensive. The critical care nurse is involved in the continuous bedside care of the critically ill patient; consequently, he or she has the opportunity to prevent sepsis through infection control practices and general nursing care, to identify patients at risk for the disease, to monitor these patients for the clinical signs of sepsis, and to detect developing organ dysfunction as a manifestation of severe sepsis. In addition, the nurse is responsible for monitoring the patient's response to organ support measures and specific antisepsis interventions. The role of the critical care nurse in the assessment and management of severe sepsis is significant and can greatly improve outcomes for the patient with this disease. Drotrecogin alfa (activated) is a promising new therapy in the treatment of severe sepsis. Nurses caring for patients with this disease need to understand the issues related to the administration of drotrecogin alfa (activated) and the monitoring of patients receiving this drug to promote optimal and appropriate use of this innovative therapy.

Relevance of neuropeptide Y for the neuroimmune crosstalk

Both cellular and humoral functions of the immune system are modulated by the sympathetic nervous system (SNS). This interaction is mainly mediated by the release of catecholamines (CA) and their receptor-specific action on immune cells. However, neuropeptide Y (NPY), also present in sympathetic nerve terminals, is released upon SNS-stimulation. NPY modulates potent immunological effects in vitro and in vivo, such as differentiation of T helper cells, monocyte mediator release, NK cell activation, and immune cell redistribution. In addition to this direct action within the neuroimmune crosstalk, NPY is also able to modulate the immunomodulatory effects of other neurotransmitters, thereby acting as a neuroimmune co-transmitter. This review will discuss key findings from recent studies, provide implications for the clinical situation, and integrate the pleiotropic functions of NPY in the context of neuroimmune interactions.

Tumor necrosis factor-alpha and interleukin-1beta mediate endothelial permeability induced by lipopolysaccharide-stimulated whole blood

OBJECTIVE

To investigate the role of endotoxin-induced inflammatory mediators in blood on the permeability of endothelial monolayers.

DESIGN

Whole blood of healthy volunteers was treated with bacterial lipopolysaccharide (Escherichia coli, B55:05), and the resultant plasma was added to human umbilical venular endothelial cells (HUVEC) cultured on semipermeable membrane inserts (Transwells).

SETTING

University hospital laboratory.

SUBJECTS

Whole blood of healthy volunteers.

INTERVENTIONS

Donor plasma was treated with excess antibodies against either tumor necrosis factor-alpha, interleukin-1beta, or both, before the incubation on HUVEC.

MEASUREMENTS AND MAIN RESULTS

The permeability of HUVEC monolayers to fluorescent-labeled albumin and dextran was measured over a 6-hr period, after removal of the stimulus. The production of tumor necrosis factor-alpha and interleukin-1beta in lipopolysaccharide-treated whole blood was determined by radioimmunoassay. Individually, lipopolysaccharide (10 microg/mL), tumor necrosis factor-alpha (10 ng/mL), and interleukin-1beta (50 ng/mL) all increased endothelial permeability by about 2.5-fold. A much larger increase could be achieved by preincubation of lipopolysaccharide (10 microg/mL) in whole blood: the resultant plasma induced a ten-fold increase of the permeability. The permeability response after preincubation of lipopolysaccharide in whole blood was time- and dose-dependent. Moreover, this treatment increased the sensitivity of endothelial monolayers to lipopolysaccharide by a factor of several thousand-fold: Whereas high doses of lipopolysaccharide were required for direct stimulation of the permeability, picomolar amounts of lipopolysaccharide in whole blood induced a similar increase. Significant amounts of tumor necrosis factor-alpha and interleukin-1beta were produced in blood at similar doses of lipopolysaccharide. The addition of antibodies against tumor necrosis factor-alpha or interleukin-1beta to plasma partially but significantly abrogated the permeability increase. However, a complete inhibition could be achieved by the simultaneous addition of anti-tumor necrosis factor-alpha and anti-interleukin-1beta to plasma.

CONCLUSIONS

Although lipopolysaccharide is capable of directly inducing endothelial permeability, blood-borne tumor necrosis factor-alpha and interleukin-1beta mediate lipopolysaccharide-induced endothelial permeability at low endotoxin concentrations. These findings support the idea that multifactorial inhibition of inflammatory mediators may improve survival in septic patients.

Systemic LPS injection leads to granulocyte influx into normal and injured brain: effects of ICAM-1 deficiency

The lipopolysaccharide (LPS) constituents of the gram-negative bacterial wall are among the most potent activators of inflammation. In the current study, we examined the effect of subcutaneous injection of Escherichia coli LPS on leukocyte influx into the normal and injured brain using endogenous peroxidase (EP). Normal brain parenchyma does not contain granulocytes and this does not change after indirect trauma, in facial axotomy. However, systemic injection of 1 mg LPS led to a gradual appearance of EP-positive parenchymal granulocytes within 12 h, with a maximum at 1-4 days after injection. Facial axotomy (day 14) led to a further 50-300% increase in granulocyte number. Of the five mouse strains tested in the current study, four--Balb/C, FVB, C57Bl/6, and C3H/N--showed vigorous granulocyte influx (60-90 cells per 20-microm section in axotomized facial nucleus, 20-40 cells per section on the contralateral side). The influx was an order of magnitude lower in the SJL mice. The peroxidase-positive cells were immunoreactive for neutrophil antigen 7/4 and alpha M beta 2 integrin, were negative for IBA1 (monocytes) and CD3 (T cells), and could be prelabeled by subcutaneous injection with rhodamine B isothiocyanate (RITC), confirming their origin as blood-borne granulocytes. All RITC-positive cells were IBA1 negative. This influx of granulocytes was accompanied by a disruption of the blood-brain barrier to albumin and induction of the cell adhesion molecule ICAM-1 on affected blood vessels. Transgenic deletion of ICAM-1 led to a more than 50% reduction in the number of infiltrating granulocytes compared to litter-matched wild-type controls, in normal brain as well as in axotomized facial motor nucleus. In summary, systemic injection of LPS leads to invasion of granulocytes into the mouse brain and a breakdown of the blood-brain barrier to blood-borne cells and to soluble molecules. Moreover, this mechanism may play a pathogenic role in the etiology of meningitis and in severe bacterial sepsis.

The patient at risk for acute renal failure. Recognition, prevention, and preoperative optimization

Despite major advances in critical care medicine and extracorporeal renal support, the treatment of established postoperative ARF remains unsatisfactory and costly. The essential elements of perioperative renal preservation are early recognition of high-risk patients, preoperative optimization of fluid status and cardiovascular performance, intraoperative maintenance of renal perfusion, and avoidance of nephrotoxins. Pharmacologic interventions directed at preventing postoperative ARF are under intense investigation but presently are limited to renal transplant surgery.