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Xavier MS, Vane MF, Vieira RF, Oliveira CC, Maia DRR, de Castro LUC, Carmona MJC, Costa Auler JO, Otsuki DA. Methylene blue as an adjuvant during cardiopulmonary resuscitation: an experimental study in rats. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2024; 74:744470. [PMID: 37926365 DOI: 10.1016/j.bjane.2023.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 10/09/2023] [Accepted: 10/13/2023] [Indexed: 11/07/2023]
Abstract
INTRODUCTION Methylene Blue (MB) has been shown to attenuate oxidative, inflammatory, myocardial, and neurological lesions during ischemia-reperfusion and has great potential during cardiac arrest. This study aimed to determine the effects of MB combined with epinephrine during cardiac arrest on myocardial and cerebral lesions. METHOD Thirty-eight male Wistar rats were randomly assigned to four groups: the sham group (SH, n = 5), and three groups subjected to cardiac arrest (n = 11/group) and treated with EPI 20 µg.kg-1 (EPI), EPI 20 µg.kg-1 + MB 2 mg.kg-1 (EPI + MB), or saline 0.9% 0.2 ml (CTL). Ventricular fibrillation was induced by direct electrical stimulation in the right ventricle for 3 minutes, and anoxia was maintained for 5 minutes. Cardiopulmonary Resuscitation (CPR) consisted of medications, ventilation, chest compressions, and defibrillation. After returning to spontaneous circulation, animals were observed for four hours. Blood gas, troponin, oxidative stress, histology, and TUNEL staining measurements were analyzed. Groups were compared using generalized estimating equations. RESULTS No differences in the Returning of Spontaneous Circulation (ROSC) rate were observed among the groups (EPI: 63%, EPI + MB: 45%, CTL: 40%, p = 0.672). The mean arterial pressure immediately after ROSC was higher in the EPI+MB group than in the CTRL group (CTL: 30.5 [5.8], EPI: 63 [25.5], EPI+MB: 123 [31] mmHg, p = 0.007). Serum troponin levels were high in the CTL group (CTL: 130.1 [333.8], EPI: 3.70 [36.0], EPI + MB: 43.7 [116.31] ng/mL, p < 0.05). CONCLUSION The coadministration of MB and epinephrine failed to yield enhancements in cardiac or brain lesions in a rodent model of cardiac arrest.
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Affiliation(s)
- Marcelo Souza Xavier
- Faculdade de Medicina da Universidade de São Paulo (FMUSP), Laboratório de Investigação Médica n 8 (LIM-8), Anestesiologia, São Paulo, SP, Brazil
| | - Matheus F Vane
- Faculdade de Medicina da Universidade de São Paulo (FMUSP), Laboratório de Investigação Médica n 8 (LIM-8), Anestesiologia, São Paulo, SP, Brazil
| | - Roberta F Vieira
- Faculdade de Medicina da Universidade de São Paulo (FMUSP), Laboratório de Investigação Médica n 8 (LIM-8), Anestesiologia, São Paulo, SP, Brazil
| | - Cristiano C Oliveira
- Faculdade de Medicina da Universidade de São Paulo (FMUSP), Laboratório de Investigação Médica n 8 (LIM-8), Anestesiologia, São Paulo, SP, Brazil
| | - Debora R R Maia
- Faculdade de Medicina da Universidade de São Paulo (FMUSP), Laboratório de Investigação Médica n 8 (LIM-8), Anestesiologia, São Paulo, SP, Brazil
| | - Leticia U C de Castro
- Faculdade de Medicina da Universidade de São Paulo (FMUSP), Laboratório de Investigação Médica n 8 (LIM-8), Anestesiologia, São Paulo, SP, Brazil
| | - Maria José Carvalho Carmona
- Faculdade de Medicina da Universidade de São Paulo (FMUSP), Laboratório de Investigação Médica n 8 (LIM-8), Anestesiologia, São Paulo, SP, Brazil
| | - José Otávio Costa Auler
- Faculdade de Medicina da Universidade de São Paulo (FMUSP), Laboratório de Investigação Médica n 8 (LIM-8), Anestesiologia, São Paulo, SP, Brazil
| | - Denise Aya Otsuki
- Faculdade de Medicina da Universidade de São Paulo (FMUSP), Laboratório de Investigação Médica n 8 (LIM-8), Anestesiologia, São Paulo, SP, Brazil.
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Heitzer M, Kilic K, Merfort R, Emonts C, Winnand P, Kniha K, Hölzle F, Modabber A. Evaluation of fibrin, cyanoacrylate, and polyurethane-based tissue adhesives in sutureless vascular anastomosis: a comparative mechanical ex vivo study. Int J Oral Maxillofac Surg 2023; 52:1137-1144. [PMID: 37019734 DOI: 10.1016/j.ijom.2023.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 03/18/2023] [Accepted: 03/21/2023] [Indexed: 04/05/2023]
Abstract
The stability of a microvascular anastomosis is an important prerequisite for successful tissue transfer. Advances in tissue adhesives are potentially opening new avenues for their use in sutureless microsurgical anastomosis, however they have not yet gained clinical acceptance. In this ex vivo study, a novel polyurethane-based adhesive (PA) was used in sutureless anastomoses and its stability compared with that of sutureless anastomoses performed with fibrin glue (FG) and a cyanoacrylate (CA). Stability was assessed using hydrostatic (15 per group) and mechanical tests (13 per group). A total of 84 chicken femoral arteries were used in this study. The time taken to create the PA and CA anastomoses was significantly faster when compared to the FG anastomoses (P < 0.001): 1.55 ± 0.14 min and 1.39 ± 0.06 min, respectively, compared to 2.03 ± 0.35 min. Both sustained significantly higher pressures (289.3 mmHg and 292.7 mmHg, respectively) than anastomoses using FG (137.3 mmHg) (P < 0.001). CA anastomoses (0.99 N; P < 0.001) and PA anastomoses (0.38 N; P = 0.009) could both withstand significantly higher longitudinal tensile forces compared to FG anastomoses (0.10 N). Considering the background of an in vitro study, the PA and CA anastomosis techniques were shown to be similar to each other and superior to FG, due to their stability and faster handling. These findings need to be validated and confirmed in further in vivo studies.
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Affiliation(s)
- M Heitzer
- Department of Oral and Maxillofacial Surgery, University Hospital of RWTH Aachen, Aachen, Germany.
| | - K Kilic
- Department of Oral and Maxillofacial Surgery, University Hospital of RWTH Aachen, Aachen, Germany
| | - R Merfort
- Department of Orthopaedics, Trauma and Reconstructive Surgery, University Hospital of RWTH Aachen, Aachen, Germany
| | - C Emonts
- Institut für Textiltechnik, RWTH Aachen University, Aachen, Germany
| | - P Winnand
- Department of Oral and Maxillofacial Surgery, University Hospital of RWTH Aachen, Aachen, Germany
| | - K Kniha
- Department of Oral and Maxillofacial Surgery, University Hospital of RWTH Aachen, Aachen, Germany
| | - F Hölzle
- Department of Oral and Maxillofacial Surgery, University Hospital of RWTH Aachen, Aachen, Germany
| | - A Modabber
- Department of Oral and Maxillofacial Surgery, University Hospital of RWTH Aachen, Aachen, Germany
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Abstract
Cardiogenic shock is characterized by tissue hypoxia caused by circulatory failure arising from inadequate cardiac output. In addition to treating the pathologic process causing impaired cardiac function, prompt hemodynamic support is essential to reduce the risk of developing multiorgan dysfunction and to preserve cellular metabolism. Pharmacologic therapy with the use of vasopressors and inotropes is a key component of this treatment strategy, improving perfusion by increasing cardiac output, altering systemic vascular resistance, or both, while allowing time and hemodynamic stability to treat the underlying disease process implicated in the development of cardiogenic shock. Despite the use of mechanical circulatory support recently garnering significant interest, pharmacologic hemodynamic support remains a cornerstone of cardiogenic shock management, with over 90% of patients receiving at least 1 vasoactive agent. This review aims to describe the pharmacology and hemodynamic effects of current pharmacotherapies and provide a practical approach to their use, while highlighting important future research directions.
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Affiliation(s)
- Jason E. Bloom
- Department of CardiologyAlfred HealthMelbourneAustralia
- Baker Heart and Diabetes InstituteMelbourneAustralia
- Department of Epidemiology and Preventive MedicineMonash UniversityMelbourneAustralia
| | - William Chan
- Department of CardiologyAlfred HealthMelbourneAustralia
- Baker Heart and Diabetes InstituteMelbourneAustralia
| | - David M. Kaye
- Department of CardiologyAlfred HealthMelbourneAustralia
- Baker Heart and Diabetes InstituteMelbourneAustralia
| | - Dion Stub
- Department of CardiologyAlfred HealthMelbourneAustralia
- Department of Epidemiology and Preventive MedicineMonash UniversityMelbourneAustralia
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Luis-Silva F, Menegueti MG, Sato L, Peres LM, dos Reis Sepeda C, Petroski-Moraes BC, Donadel MD, Gallo GB, Jordani MC, Mestriner F, Becari C, Basile-Filho A, Evora PRB, Martins-Filho OA, Auxiliadora-Martins M. Effect of methylene blue on hemodynamic response in the early phase of septic shock: A case series. Medicine (Baltimore) 2023; 102:e32743. [PMID: 36705345 PMCID: PMC9875988 DOI: 10.1097/md.0000000000032743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
RATIONALE Methylene blue (MB) has been used to increase blood pressure in septic shock, acting on the activity of guanylate cyclase and nitric oxide synthase. PATIENCE CONCERNS The aim of this study is to demonstrate the benefit of MB in early phase of septic shock.Diagnoses: We report 6 cases of patients with septic shock with up to 72 hours of evolution. INTERVENTIONS We used MB after fluid replacement, use of norepinephrine and vasopressin. Patients received a loading dose of MB and maintenance for 48 hours. OUTCOMES All patients presented a reduction in the dose of vasopressors and lactate levels soon after the administration of the loading dose of MB, an effect that was maintained with the maintenance dose for 48 hours. Interleukin 6 and interleukin 8 were elevated at the beginning of the septic condition, with a progressive and marked reduction after the beginning of MB infusion, demonstrating a role of MB in reducing the inflammatory activity. LESSONS This case series suggests that MB used early in the treatment of septic shock may be useful in reducing vasopressor dose and lactate levels. Further studies are still required to further validate these findings.
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Affiliation(s)
- Fabio Luis-Silva
- Division of Intensive Care Medicine, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
- * Correspondence: Maria Auxiliadora-Martins, Division of Intensive Care Medicine, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo 14048-900, Brazil (e-mail: )
| | | | - Lucas Sato
- Division of Intensive Care Medicine, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Leandro Moreira Peres
- Division of Intensive Care Medicine, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Corina dos Reis Sepeda
- Division of Intensive Care Medicine, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Bruno C. Petroski-Moraes
- Division of Intensive Care Medicine, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Mariana Dermínio Donadel
- Division of Intensive Care Medicine, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Gabriela Bortoleto Gallo
- Division of Intensive Care Medicine, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Maria Cecília Jordani
- Division of Cardiac Surgery, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Fabiola Mestriner
- Division of Vascular and Endovascular Surgery, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Christiane Becari
- Division of Vascular and Endovascular Surgery, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Anibal Basile-Filho
- Division of Intensive Care Medicine, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Paulo R. B. Evora
- Division of Cardiac Surgery, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | | | - Maria Auxiliadora-Martins
- Division of Intensive Care Medicine, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
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Leone M, Einav S, Antonucci E, Depret F, Lakbar I, Martin-Loeches I, Wieruszewski PM, Myatra SN, Khanna AK. Multimodal strategy to counteract vasodilation in septic shock. Anaesth Crit Care Pain Med 2023; 42:101193. [PMID: 36621622 DOI: 10.1016/j.accpm.2023.101193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 12/26/2022] [Accepted: 12/30/2022] [Indexed: 01/07/2023]
Abstract
Early initiation of a multimodal treatment strategy in the management of vasopressors during septic shock has been advocated to reduce delays in restoring adequate organ perfusion and to mitigate side effects associated with the administration of high-dose catecholamines. We provide a review that summarises the pathophysiology of vasodilation, the physiologic response to the vascular response, and the different drugs used in this situation, focusing on the need to combine early different vasopressors. Fluid loading being insufficient for counteracting vasoplegia, norepinephrine is usually the first-line vasopressor used to restore hemodynamics. Norepinephrine sparing is discussed in further detail through the concomitant use of adrenergic, vasopressinergic, and renin-angiotensin systems and the optimisation of endothelial reactivity with methylene blue. A blueprint for the construction of new studies is outlined to address the question of vasopressor selection and timing in septic shock.
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Affiliation(s)
- Marc Leone
- Department of Anesthesiology and Intensive Care Unit, North Hospital, Aix Marseille University, Assistance Publique Hôpitaux Universitaires de Marseille, Marseille, France.
| | - Sharon Einav
- Surgical Intensive Care, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Elio Antonucci
- Intermediate Care Unit, Emergency Department, Ospedale Guglielmo da Saliceto, Piacenza, Italy
| | - François Depret
- GH St-Louis-Lariboisière, Department of Anesthesiology and Critical Care and Burn Unit, St-Louis Hospital, Assistance Publique-Hopitaux de Paris, Paris, France
| | - Ines Lakbar
- Department of Anesthesiology and Intensive Care Unit, North Hospital, Aix Marseille University, Assistance Publique Hôpitaux Universitaires de Marseille, Marseille, France
| | - Ignacio Martin-Loeches
- Intensive Care Unit, Trinity Centre for Health Science HRB-Wellcome Trust, St James's Hospital, Dublin, Ireland
| | | | - Sheila Nainan Myatra
- Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Ashish K Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, USA; Outcomes Research Consortium, Cleveland, OH, USA
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Muacevic A, Adler JR, Boyer GA, Pathak V. Methylene Blue in Refractory Shock. Cureus 2022; 14:e31158. [PMID: 36505110 PMCID: PMC9728991 DOI: 10.7759/cureus.31158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2022] [Indexed: 11/09/2022] Open
Abstract
Many patients suffer shock in intensive care units (ICU). The majority of the patients with shock respond to standard treatment with vasopressors in addition to the treatment of underlying etiology. Some may not respond to vasopressors and have high mortality. To those patients who do not respond, methylene blue has been used in the past with some success. We present a case report on the use of methylene blue along with a brief literature review.
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Sari-Yavuz S, Heck-Swain KL, Keller M, Magunia H, Feng YS, Haeberle HA, Wied P, Schlensak C, Rosenberger P, Koeppen M. Methylene blue dosing strategies in critically ill adults with shock-A retrospective cohort study. Front Med (Lausanne) 2022; 9:1014276. [PMID: 36388905 PMCID: PMC9650001 DOI: 10.3389/fmed.2022.1014276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 10/07/2022] [Indexed: 12/13/2022] Open
Abstract
Background Shock increases mortality in the critically ill and the mainstay of therapy is the administration of vasopressor agents to achieve hemodynamic targets. In the past, studies have found that the NO-pathway antagonist methylene blue improves hemodynamics. However, the optimal dosing strategy remains elusive. Therefore, we investigated the hemodynamic and ICU outcome parameters of three different dosing strategies for methylene blue. Methods We performed a retrospective cohort study of patients in shock treated with methylene blue. Shock was defined as norepinephrine dose >0.1 μg/kg/min and serum lactate level >2 mmol/l at the start of methylene blue administration. Different demographic variables, ICU treatment, and outcome parameters were evaluated. To compare the differences in the administration of vasopressors or inotropes, the vasoactive inotropic score (VIS) was calculated at different time points after starting the administration of methylene blue. Response to methylene blue or mortality at 28 days were assessed. Results 262 patients from July 2014 to October 2019 received methylene blue. 209 patients met the inclusion criteria. Three different dosing strategies were identified: bolus injection followed by continuous infusion (n = 111), bolus injection only (no continuous infusion; n = 59) or continuous infusion only (no bolus prior; n = 39). The groups did not differ in demographics, ICU scoring system, or comorbidities. In all groups, VIS decreased over time, indicating improved hemodynamics. Cardiogenic shock and higher doses of norepinephrine increased the chance of responding to methylene blue, while bolus only decreased the chance of responding to methylene blue treatment. 28-day mortality increased with higher SAPSII scores and higher serum lactate levels, while bolus injection followed by continuous infusion decreased 28-day mortality. No severe side effects were noted. Conclusion In this cohort, methylene blue as a bolus injection followed by continuous infusion was associated with a reduced 28-day mortality in patients with shock. Prospective studies are needed to systematically evaluate the role of methylene blue in the treatment of shock.
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Affiliation(s)
- Sibel Sari-Yavuz
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Tübingen, Tübingen, Germany
| | - Ka-Lin Heck-Swain
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Tübingen, Tübingen, Germany
| | - Marius Keller
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Tübingen, Tübingen, Germany
| | - Harry Magunia
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Tübingen, Tübingen, Germany
| | - You-Shan Feng
- Institute for Clinical Epidemiology and Applied Biostatistics (IKEaB), Eberhard-Karls-University Tübingen, Tübingen, Germany
| | - Helene A. Haeberle
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Tübingen, Tübingen, Germany
| | - Petra Wied
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Tübingen, Tübingen, Germany
| | - Christian Schlensak
- Department of Thoracic and Cardiovascular Surgery, University Hospital Tübingen, Tübingen, Germany
| | - Peter Rosenberger
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Tübingen, Tübingen, Germany
| | - Michael Koeppen
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Tübingen, Tübingen, Germany,*Correspondence: Michael Koeppen
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Zhao CC, Zhai YJ, Hu ZJ, Huo Y, Li ZQ, Zhu GJ. Efficacy and safety of methylene blue in patients with vasodilatory shock: A systematic review and meta-analysis. Front Med (Lausanne) 2022; 9:950596. [PMID: 36237547 PMCID: PMC9552293 DOI: 10.3389/fmed.2022.950596] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 09/01/2022] [Indexed: 12/03/2022] Open
Abstract
Background The role of methylene blue (MB) in patients with vasodilatory shock is unclear. The purpose of this systematic review and meta-analysis was to evaluate the efficacy and safety of MB in patients with vasodilatory shock. Methods We searched MEDLINE at PubMed, Embase, Web of Science, Cochrane, CNKI, CBM and Wanfang Medical databases for all observational and intervention studies comparing the effect of MB vs. control in vasodilatory shock patients. This study was performed in accordance with the PRISMA statement. There were no language restrictions for inclusion. Results A total of 15 studies with 832 patients were included. Pooled data demonstrated that administration of MB along with vasopressors significantly reduced mortality [odds ratio (OR) 0.54, 95% confidence interval (CI) 0.34 to 0.85, P = 0.008; I 2 = 7%]. This benefit in mortality rate was also seen in a subgroup analysis including randomized controlled trials and quasi-randomized controlled trials. In addition, the vasopressor requirement was reduced in the MB group [mean difference (MD) -0.77, 95%CI -1.26 to -0.28, P = 0.002; I 2 = 80%]. Regarding hemodynamics, MB increased the mean arterial pressure, heart rate and peripheral vascular resistance. In respect to organ function, MB was associated with a lower incidence of renal failure, while in regards to oxygen metabolism, it was linked to reduced lactate levels. MB had no effect on the other outcomes and no serious side effects. Conclusions Concomitant administration of MB and vasopressors improved hemodynamics, decreased vasopressor requirements, reduced lactate levels, and improved survival in patients with vasodilatory shock. However, further studies are required to confirm these findings. Systematic review registration Identifier: CRD42021281847.
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Affiliation(s)
- Cong-Cong Zhao
- Department of Intensive Care Unit, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yu-Jia Zhai
- Department of Intensive Care Unit, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Zhen-Jie Hu
- Department of Intensive Care Unit, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yan Huo
- Department of Intensive Care Unit, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Zhi-Qiang Li
- Department of Intensive Care Unit, Affiliated Hospital of North China University of Science and Technology, Tangshan, China
| | - Gui-Jun Zhu
- Department of Intensive Care Unit, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
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Synthesis of Metalorganic Copolymers Containing Various Contorted Units and Iron(II) Clathrochelates with Lateral Butyl Chains: Conspicuous Adsorbents of Lithium Ions and Methylene Blue. Polymers (Basel) 2022; 14:polym14163394. [PMID: 36015650 PMCID: PMC9412635 DOI: 10.3390/polym14163394] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 08/16/2022] [Accepted: 08/17/2022] [Indexed: 12/12/2022] Open
Abstract
We report the synthesis of three highly soluble metalorganic copolymers, TCP1-3, that were made from a one-pot complexation of iron(II) clathrochelate units that are interconnected by various thioether-containing contorted groups. TCP1-3 were converted into their poly(vinyl sulfone) derivatives OTCP1-3 quantitatively via the selective oxidation of the thioether moieties into their respective sulfones. All of the copolymers, TCP1-3 and OTCP1-3, underwent structural analysis by various techniques; namely, 1H- and 13C-nuclear magnetic resonance (NMR), Fourier transform infrared (FTIR), X-ray photoelectron spectroscopy (XPS), and gel permeation chromatography (GPC). The copolymers were tested as potent lithium ions adsorbents revealing a maximum adsorption (qm) value of 2.31 mg g-1 for OTCP2. Furthermore, this same copolymer was found to be a promising adsorbent of methylene blue (MEB); an isothermal adsorption study divulged that OTCP2's uptake of MEB from an aqueous solution (following the Langmuir model) was, at maximum adsorption capacity, (qm) of 480.77 mg g-1; whereas the kinetic study divulged that the adsorption follows pseudo second-order kinetics with an equilibrium adsorption capacity (qe,cal) of 45.40 mg g-1.
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10
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Albertson TE, Chenoweth JA, Lewis JC, Pugashetti JV, Sandrock CE, Morrissey BM. The pharmacotherapeutic options in patients with catecholamine-resistant vasodilatory shock. Expert Rev Clin Pharmacol 2022; 15:959-976. [PMID: 35920615 DOI: 10.1080/17512433.2022.2110067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Septic and vasoplegic shock are common types of vasodilatory shock (VS) with high mortality. After fluid resuscitation and the use of catecholamine-mediated vasopressors (CMV), vasopressin, angiotensin II, methylene blue (MB) and hydroxocobalamin can be added to maintain blood pressure. AREAS COVERED VS treatment utilizes a phased approach with secondary vasopressors added to vasopressor agents to maintain an acceptable mean arterial pressure (MAP). This review covers additional vasopressors and adjunctive therapies used when fluid and catecholamine-mediated vasopressors fail to maintain target MAP. EXPERT OPINION Evidence supporting additional vasopressor agents in catecholamine resistant VS is limited to case reports, series, and a few randomized control trials (RCTs) to guide recommendations. Vasopressin is the most common agent added next when MAPs are not adequately supported with CMV. VS patients failing fluids and vasopressors with cardiomyopathy may have cardiotonic agents such as dobutamine or milrinone added before or after vasopressin. Angiotensin II, another class of vasopressor is used in VS to maintain adequate MAP. MB and/or hydoxocobalamin, vitamin C, thiamine and corticosteroids are adjunctive therapies used in refractory VS. More RCTs are needed to confirm the utility of these drugs, at what doses, which combinations and in what order they should be given.
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Affiliation(s)
- Timothy E Albertson
- Department of Internal Medicine, University of California, Davis, Sacramento, CA, USA.,Department of Emergency Medicine, University of California, Davis, Sacramento, CA, USA.,Department of Medicine, VA Northern California Health System, Mather, CA, USA.,Department of Clinical Pharmacy, University of California, San Francisco, CA, USA
| | - James A Chenoweth
- Department of Emergency Medicine, University of California, Davis, Sacramento, CA, USA.,Department of Medicine, VA Northern California Health System, Mather, CA, USA
| | - Justin C Lewis
- Department of Internal Medicine, University of California, Davis, Sacramento, CA, USA.,Department of Clinical Pharmacy, University of California, San Francisco, CA, USA
| | - Janelle V Pugashetti
- Department of Internal Medicine, University of California, Davis, Sacramento, CA, USA.,Department of Medicine, VA Northern California Health System, Mather, CA, USA
| | - Christian E Sandrock
- Department of Internal Medicine, University of California, Davis, Sacramento, CA, USA.,Department of Medicine, VA Northern California Health System, Mather, CA, USA
| | - Brian M Morrissey
- Department of Internal Medicine, University of California, Davis, Sacramento, CA, USA.,Department of Medicine, VA Northern California Health System, Mather, CA, USA
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11
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Naoum EE, Dalia AA, Roberts RJ, Devine LT, Ortoleva J. Methylene blue for vasodilatory shock in the intensive care unit: a retrospective, observational study. BMC Anesthesiol 2022; 22:199. [PMID: 35761204 PMCID: PMC9235079 DOI: 10.1186/s12871-022-01739-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 06/20/2022] [Indexed: 01/26/2023] Open
Abstract
Abstract
Background
Refractory vasodilatory shock is a state of uncontrolled vasodilation associated with underlying inflammation and endothelial dysregulation. Rescue therapy for vasoplegia refractory to catecholamines includes methylene blue (MB) which restores vascular tone. We hypothesized that (1) at least 40% of critically ill patients would respond positively to MB administration and (2) that those who responded to MB would have a survival benefit.
Methods
This study was a retrospective review that included all adult patients admitted to an intensive care unit treated with MB for the indication of refractory vasodilatory shock. Responders to MB were identified as those with a ≥ 10% increase in mean arterial pressure (MAP) within the first 1-2 hours after administration. We examined the association of mortality to the groups of responders versus non-responders to MB. A subgroup analysis in patients undergoing continuous renal replacement therapy (CRRT) was also performed.
Statistical calculations were performed in Microsoft Excel® (Redmond, WA, USA). Where appropriate, the comparison of averages and standard deviations of demographics, dosing, MAP, and reductions in vasopressor dosing were performed via Chi squared, Fisher's exact test, or two-tailed t-test with a p-value < 0.05 being considered as statistically significant. After using the F-test to assess for differences in variance, the proper two tailed t-test was used to compare SOFA scores among responders versus non-responders.
Results
A total of 223 patients were included in the responder analysis; 88 (39.5%) had a ≥ 10% increase in MAP post-MB administration that was not associated with a significant change in norepinephrine requirements between responders versus non-responders (p=0.41). There was a non-statistically significant trend (21.6% vs 14.8%, p=0.19) toward improved survival to hospital discharge in the MB responder group compared to the non-responder group. In 70 patients undergoing CRRT, there were 33 responders who were more likely to survive than those who were not (p = 0.0111).
Conclusions
In patients with refractory shock receiving MB, there is a non-statistically significant trend toward improved outcomes in responders based on a MAP increase >10%. Patients supported with CRRT who were identified as responders had decreased ICU mortality compared to non-responders.
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12
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Ramaswamy P, Gong JJ, Saleh SN, McDonald SA, Blumberg S, Medford RJ, Liu X. Developing a COVID-19 WHO Clinical Progression Scale inpatient database from electronic health record data. J Am Med Inform Assoc 2022; 29:1279-1285. [PMID: 35289912 PMCID: PMC9196693 DOI: 10.1093/jamia/ocac041] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 03/05/2022] [Accepted: 03/14/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE There is a need for a systematic method to implement the World Health Organization's Clinical Progression Scale (WHO-CPS), an ordinal clinical severity score for coronavirus disease 2019 patients, to electronic health record (EHR) data. We discuss our process of developing guiding principles mapping EHR data to WHO-CPS scores across multiple institutions. MATERIALS AND METHODS Using WHO-CPS as a guideline, we developed the technical blueprint to map EHR data to ordinal clinical severity scores. We applied our approach to data from 2 medical centers. RESULTS Our method was able to classify clinical severity for 100% of patient days for 2756 patient encounters across 2 institutions. DISCUSSION Implementing new clinical scales can be challenging; strong understanding of health system data architecture was integral to meet the clinical intentions of the WHO-CPS. CONCLUSION We describe a detailed blueprint for how to apply the WHO-CPS scale to patient data from the EHR.
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Affiliation(s)
- Priya Ramaswamy
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California, USA.,Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, California, USA
| | - Jen J Gong
- Center of Clinical Informatics and Improvement Research, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Sameh N Saleh
- Clinical Informatics Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA.,Section of Hospital Medicine, Division of General Internal Medicine, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA.,Department of Biomedical & Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Samuel A McDonald
- Clinical Informatics Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA.,Department of Emergency Medicine, University of Texas Southwestern Medical Center, Clinical Informatics Center, Dallas, Texas, USA
| | - Seth Blumberg
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, California, USA.,Centers of Disease Control's Modeling infectious Diseases (MInD) Healthcare Program, USA.,Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Richard J Medford
- Clinical Informatics Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA.,Department of Internal Medicine, Division of Infectious Diseases and Geographic Medicine, University of Texas Southwestern Medical Center, Clinical Informatics Center, Dallas, Texas, USA
| | - Xinran Liu
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
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13
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Domínguez-Rojas JA, Caqui P, Sanchez A, Coronado Munoz AJ. Methylene blue for the treatment of refractory septic shock secondary to listeriosis in a paediatric patient. BMJ Case Rep 2022; 15:e243772. [PMID: 35228212 PMCID: PMC8886372 DOI: 10.1136/bcr-2021-243772] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Current therapies frequently used for refractory septic shock include hydrocortisone, vasopressin, extracorporeal membrane oxygenation (ECMO) support, inodilators, levosimendan and methylene blue. The evidence for these treatments is very limited. We present a case of a 5-year-old patient with refractory septic shock, secondary to Listeria monocytogenes meningitis. She presented with status epilepticus and developed septic shock. Shock persisted despite multiple high-dose vasoactive medications. ECMO support was not available. The medical team decided to use methylene blue to revert the vasoplegia, with excellent results. Shortly after the administration, vasopressors were weaned off and the high lactate cleared. She developed severe neurological sequelae due to brain haemorrhage secondary to the Listeria meningitis. The evidence supporting methylene blue for refractory septic shock in paediatric patients is limited. This case represents the effectiveness of this therapy without secondary effects.
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Affiliation(s)
- Jesús Angel Domínguez-Rojas
- Deparment of Pediatrics, National Hospital Edgardo Rebagliati Martins, Lima, Peru
- Deparment of Critical Care, Instituto Nacional De Salud Del Niño Breña, Lima, Peru
| | - Patrick Caqui
- Department of Pediatrics, Hospital Nacional Hipolito Unanue, Lima, Peru
| | - Abel Sanchez
- Department of Pediatrics, Hospital Nacional Hipolito Unanue, Lima, Peru
| | - Alvaro J Coronado Munoz
- Deparment of Pediatrics, The University of Texas Health Science Center at Houston, Houston, Texas, USA
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14
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Luis-Silva F, Menegueti MG, Sepeda CDR, Petroski-Moraes BC, Sato L, Peres LM, Becari C, Basile-Filho A, Evora PR, Martins-Filho OA, Auxiliadora-Martins M. Effect of methylene blue on hemodynamic and metabolic response in septic shock patients. Medicine (Baltimore) 2022; 101:e28599. [PMID: 35060528 PMCID: PMC8772761 DOI: 10.1097/md.0000000000028599] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 12/29/2021] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION Septic shock is a lethal disease responsible for a large proportion of deaths in the Intensive Care Unit (ICU), even with therapy centered on fluid resuscitation, use of vasopressors and empirical antibiotic therapy applied within the first hour of diagnosis. Considering the multifactorial pathophysiology of septic shock and the mechanism of action of vasopressors, some patients may not respond adequately, which can lead to the maintenance of vasodilatation, hypotension and increased morbidity, and mortality. This protocol aims to verify whether the use of methylene blue in septic patients with an early diagnosis can contribute to an earlier resolution of a shock compared to standard treatment. METHODS AND ANALYSIS This is a study protocol for a single-center randomized clinical trial design in an ICU of a tertiary university hospital. In this study, we intend to include 64 patients aged between 18 and 80 years with a diagnosis of septic shock, of any etiology, with up to 72 hours of evolution after volume restoration, using norepinephrine at a dose ≥0.2 μg/kg/min and vasopressin at a dose of 0.04 IU/min. After the initial approach, we will randomize patients into two groups, standard care, and standard care plus methylene blue. The sample size was calculated in order to show 30% differences in septic shock resolution between groups. The Research Ethics Committee approved the study, and all patients included will sign an informed consent form (Clinical registration: RBR-96584w4).
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Affiliation(s)
- Fabio Luis-Silva
- Division of Intensive Care Medicine, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
- Professor of Clinical Medicine, Barao de Maua University Center - Ribeirão Preto / São Paulo, Brazil
| | | | - Corina dos Reis Sepeda
- Division of Intensive Care Medicine, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Bruno C. Petroski-Moraes
- Division of Intensive Care Medicine, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Lucas Sato
- Division of Intensive Care Medicine, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Leandro Moreira Peres
- Division of Intensive Care Medicine, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Christiane Becari
- Division of Vascular and Endovascular Surgery, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Anibal Basile-Filho
- Division of Intensive Care Medicine, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Paulo R.B. Evora
- Division of Cardiac Surgery, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | | | - Maria Auxiliadora-Martins
- Division of Intensive Care Medicine, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
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15
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Szabó T, Kormos V, Rékási Z, Gaszner B. Epineural Methylene Blue Injection May Aid Localization of Digital Nerves in Dupuytren's Surgery. Eur Surg Res 2021; 63:105-113. [PMID: 34689139 PMCID: PMC9501739 DOI: 10.1159/000519666] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 09/11/2021] [Indexed: 12/05/2022]
Abstract
Background In Dupuytren's surgery, limited fasciectomy is still the gold-standard treatment. A relatively high risk of iatrogenic nerve injury has been observed especially when the spiral cords of the Dupuytren's tissue pull digital nerves away from their normal anatomical location. Intraoperative neural marking could facilitate locating the potentially displaced nerves. Hence, surgery could be undertaken more quickly with a lower risk of iatrogenic nerve injury. Objectives We hypothesize that digital nerves may be stained with methylene blue (MB) in vivo providing a visual aid to distinguish them from Dupuytren's tissue. We aim to (a) test an in vivo nerve staining technique using MB in a rat sciatic nerve model and to (b) assess the safety of epineural MB injection. Methods Three experiments were performed: first, the effects of (a) sham surgery, (b) epineural needle insertion, and (c) 40 μL epineural saline injection were tested in the rat sciatic nerve. Second, we determined the (a) histoanatomical localization of the epineurally injected 40 µL 1 m/m% MB stock solution and (b) we tested which saline dilution (i.e., 1:40, 1:80, and 1:160) of the stock solution does provide optimal blue color upon 40 µL epineural injection. Third, the functional and morphological effect of 40 µL 1:80 diluted MB injection was compared with that of saline, injected into the contralateral sciatic nerve. The functional effects were tested by assessing the pain threshold by using a dynamic plantar esthesiometer (DPA) and by examination of the animal's gate and paw posture. Sciatic nerves were subjected to histological examination and morphometry to test structural damage. Results Neither epineural needle insertion nor saline injection caused any functional or morphological changes. Histological examination revealed that the MB stained the epineural compartment. Epineural injection of 40 μL 1:80 diluted MB into the sciatic nerve stained an 18.18-mm segment of the nerve distal to the puncture point. DPA revealed unchanged pain threshold values on the plantar surface of the limbs. Normal gait and foot posture suggested normal motor functions in all groups. No histological changes were seen in the stained nerves, and the nerve fiber density remained unchanged. Conclusion We demonstrated that in vivo nerve staining with MB is a suitable method to mark nerves without causing detectable negative effect to the stained nerve. Human trials are required to prove the efficacy of the technique in Dupuytren's disease.
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Affiliation(s)
- Tamás Szabó
- Department of Traumatology and Hand Surgery, Medical School, University of Pécs, Pécs, Hungary
| | - Viktória Kormos
- Department of Pharmacology and Pharmacotherapy, Medical School, University of Pécs, Pécs, Hungary
| | - Zoltán Rékási
- Department of Anatomy, Medical School, University of Pécs, Pécs, Hungary
| | - Balázs Gaszner
- Department of Anatomy, Medical School, University of Pécs, Pécs, Hungary.,Research Group for Mood Disorders, Center for Neuroscience & Szentágothai Research Center, University of Pécs, Pécs, Hungary
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16
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Marchese GA, Pascal M. Effect of methylene blue used as medical dye on blood pressure in a dog undergoing partial pancreatectomy. VETERINARY RECORD CASE REPORTS 2021. [DOI: 10.1002/vrc2.170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
| | - Manuela Pascal
- Anaesthesia and Analgesia Southfields Veterinary Specialists Basildon UK
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17
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Heitzer M, Brockhaus J, Kniha K, Merkord F, Peters F, Hölzle F, Goloborodko E, Modabber A. Mechanical strength and hydrostatic testing of VIVO adhesive in sutureless microsurgical anastomoses: an ex vivo study. Sci Rep 2021; 11:13598. [PMID: 34193930 PMCID: PMC8245481 DOI: 10.1038/s41598-021-92998-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 06/15/2021] [Indexed: 11/09/2022] Open
Abstract
Conventional anastomoses with interrupted sutures are challenging and inevitably associated with trauma to the vessel walls. The goal of this study was to evaluate a novel alternative adhesive-based suture-free anastomosis technique that uses an intraluminal stent. Overall, 120 porcine coronary vessels were analyzed in an ex vivo model and were examined for their mechanical (n = 20 per cohort) and hydrostatic strength (n = 20 per cohort). Anastomoses were made using the novel VIVO adhesive with an additional intraluminal nitinol stent and was compared to interrupted suture anastomosis and to native vessels. Sutureless anastomoses withstood pressures 299 ± 4.47 [mmHg] comparable to native vessels. They were performed significantly faster 553.8 ± 82.44 [sec] (p ≤ 0.001) and withstood significantly higher pressures (p ≤ 0.001) than sutured anastomoses. We demonstrate that the adhesive-based anastomosis can also resist unphysiologically high longitudinal tensile forces with a mean of 1.33 [N]. Within the limitations of an in vitro study adhesive-based suture-free anastomosis technique has the biomechanical potential to offer a seamless alternative to sutured anastomosis because of its stability, and faster handling. In vivo animal studies are needed to validate outcomes and confirm safety.
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Affiliation(s)
- Marius Heitzer
- Department of Oral and Maxillofacial Surgery, University Hospital of RWTH Aachen, Pauwelsstraße 13, 52074, Aachen, Germany.
| | - Julia Brockhaus
- Department of Oral and Maxillofacial Surgery, University Hospital of RWTH Aachen, Pauwelsstraße 13, 52074, Aachen, Germany
| | - Kristian Kniha
- Department of Oral and Maxillofacial Surgery, University Hospital of RWTH Aachen, Pauwelsstraße 13, 52074, Aachen, Germany
| | - Felix Merkord
- Institute of Textile Technology, RWTH Aachen University, Aachen, Germany
| | - Florian Peters
- Department of Oral and Maxillofacial Surgery, University Hospital of RWTH Aachen, Pauwelsstraße 13, 52074, Aachen, Germany
| | - Frank Hölzle
- Department of Oral and Maxillofacial Surgery, University Hospital of RWTH Aachen, Pauwelsstraße 13, 52074, Aachen, Germany
| | - Evgeny Goloborodko
- Department of Oral and Maxillofacial Surgery, University Hospital of RWTH Aachen, Pauwelsstraße 13, 52074, Aachen, Germany
| | - Ali Modabber
- Department of Oral and Maxillofacial Surgery, University Hospital of RWTH Aachen, Pauwelsstraße 13, 52074, Aachen, Germany
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18
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Keller M, Magunia H. [Vasopressors: Physiology, Pharmacology and Clinical Applications]. Anasthesiol Intensivmed Notfallmed Schmerzther 2021; 56:400-413. [PMID: 34187073 DOI: 10.1055/a-1214-4472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Vasopressors are widely used in anaesthesiology and critical care medicine, to treat harmless (e.g. anaesthesia-induced hypotension) as well as life-threatening conditions (e.g. septic shock). Some clinically used vasopressors resemble endogenous substances - such as norepinephrine - while others have been artificially synthesized (e.g. phenylephrine). Most of the substances used in different clinical scenarios have various effects except for vasoconstriction alone. Therefore, a thorough understanding of the pharmacology and clinical profile of every single substance is of highest importance prior to practical usage. Furthermore, the fundamentals of vascular physiology and vasotonic regulation are mandatory to safely provide vasopressor-based therapies. This article covers the essentials of physiology and pharmacology of vasopressors, and the clinical settings they are used in (e.g. septic shock, vasoplegic shock after cardiac surgery, trauma-induced hypotension).
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Critical Care Management of the Patient With Anaphylaxis: A Concise Definitive Review. Crit Care Med 2021; 49:838-857. [PMID: 33653974 DOI: 10.1097/ccm.0000000000004893] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Anaphylaxis is a rapidly progressive life-threatening syndrome manifesting as pruritus, urticaria, angioedema, bronchospasm and shock. The goal of this synthetic review is to provide a practical, updated approach to the evaluation and management of this disorder and associated complications. DATA SOURCES A MEDLINE search was conducted with the MeSH of anaphylaxis, anaphylactic reaction, anaphylactic shock, refractory anaphylaxis and subheadings of diagnosis, classification, epidemiology, complications and pharmacology. The level of evidence supporting an intervention was evaluated based on the availability of randomized studies, expert opinion, case studies, reviews, practice parameters and other databases (including Cochrane). STUDY SELECTION Selected publications describing anaphylaxis, clinical trials, diagnosis, mechanisms, risk factors and management were retrieved (reviews, guidelines, clinical trials, case series) and their bibliographies were also reviewed to identify relevant publications. DATA EXTRACTION Data from the relevant publications were reviewed, summarized and the information synthesized. DATA SYNTHESIS This is a synthetic review and the data obtained from a literature review was utilized to describe current trends in the diagnosis and management of the patient with anaphylaxis with a special emphasis on newer evolving concepts of anaphylaxis endotypes and phenotypes, management of refractory anaphylaxis in the ICU setting and review of therapeutic options for the elderly patient, or the complicated patient with severe cardiorespiratory complications. Most of the recommendations come from practice parameters, case studies or expert opinions, with a dearth of randomized trials to support specific interventions. CONCLUSION Anaphylaxis is a rapidly progressive life-threatening disorder. The critical care physician needs to be familiar with the diagnosis, differential diagnosis, evaluation, and management of anaphylaxis. Skilled intervention in ICUs may be required for the patient with complicated, severe, or refractory anaphylaxis.
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20
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Perdhana F, Kloping NA, Witarto AP, Nugraha D, Yogiswara N, Luke K, Kloping YP, Rehatta NM. Methylene blue for vasoplegic syndrome in cardiopulmonary bypass surgery: A systematic review and meta-analysis. Asian Cardiovasc Thorac Ann 2021; 29:717-728. [PMID: 33653154 DOI: 10.1177/0218492321998523] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND To evaluate the benefit of methylene blue as an adjunct treatment by assessing hemodynamic, morbidity rate, intensive care unit length of stay, and mortality rate outcomes in adult patients with vasoplegic syndrome. METHODS A systematic search through electronic databases including Pubmed, Embase, Scopus, and Medline for studies assessing the use of methylene blue in patients with vasoplegic syndrome compared to control treatments. The Newcastle-Ottawa Scale tool was used for observational studies, and Jadad Scale was used for controlled trials to assess the risk of bias. RESULTS This systematic review included six studies for qualitative synthesis and five studies for quantitative synthesis. Pooled analysis revealed that mean arterial pressure, systemic vascular resistance, heart rate, and hospital stay were not statistically significant in methylene blue administration compared to control. However, administration of methylene blue in vasoplegic syndrome patients significantly reduces renal failure (OR = 0.25; 95% CI = 0.08-0.75), development of multiple organ failure (OR = 0.09; 95% CI = 0.02-0.51), and mortality rate (OR = 0.12; 95% CI = 0.03-0.46). CONCLUSION Adjunct administration of methylene blue for vasoplegic syndrome patients significantly reduces renal failure, multiple organ failure, and mortality.
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Affiliation(s)
- Fajar Perdhana
- Department of Anaesthesiology and Reanimation, Faculty of Medicine, Universitas Airlangga - Dr Soetomo General Hospital, Surabaya, Indonesia
| | | | - Andro P Witarto
- Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
| | - David Nugraha
- Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
| | | | - Kevin Luke
- Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
| | | | - Nancy M Rehatta
- Department of Anaesthesiology and Reanimation, Faculty of Medicine, Universitas Airlangga - Dr Soetomo General Hospital, Surabaya, Indonesia
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Puntillo F, Giglio M, Pasqualucci A, Brienza N, Paladini A, Varrassi G. Vasopressor-Sparing Action of Methylene Blue in Severe Sepsis and Shock: A Narrative Review. Adv Ther 2020; 37:3692-3706. [PMID: 32705530 PMCID: PMC7444404 DOI: 10.1007/s12325-020-01422-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Indexed: 12/15/2022]
Abstract
Shock is a serious acute circulatory failure leading to inadequate oxygen delivery to the cells. Its treatment is mainly based on circulating fluid optimization, and vasopressors to provide an adequate mean arterial pressure and microcirculatory flow. Norepinephrine is the drug of choice, but high dosages may be responsible for several side effects, including increased myocardial oxygen consumption, dysrhythmias, and peripheral and organ ischemia. Moreover, some patients are “non-responders” to first-line norepinephrine treatment. Hence, other drugs have been proposed to reach and maintain the hemodynamic target. In general, they are described as catecholamine-sparing agents. Among others, the most used are vasopressin, corticosteroids, and angiotensin II. Methylene blue (MB) represents a further option, even though its use is still a topic of controversy. This review article tries to summarize what is known and unknown about the actions of MB in patients in shock. It reduces excessive production of nitric oxide via blockade of guanylate cyclase in shock states. At present, it appears the MB provides positive results in septic shock, if administered early. Further randomized controlled trials are warranted regarding its use to provide more precise indications to physicians involved in the treatment of such patients.
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Affiliation(s)
- Filomena Puntillo
- Department of Interdisciplinary Medicine, University of Bari "Aldo Moro", 70124, Bari, Italy
| | - Mariateresa Giglio
- Anesthesia, Intensive Care and Pain Unit, Policlinico Hospital, 70124, Bari, Italy
| | - Alberto Pasqualucci
- Department of Surgical and Biomedical Science, University of Perugia, 06100, Perugia, Italy
- Rashid Hospital, Trauma and Emergency Center, Dubai Health Authority, Dubai, UAE
| | - Nicola Brienza
- Department of Emergency and Organ Transplantation, University of Bari "Aldo Moro", 70124, Bari, Italy
| | | | - Giustino Varrassi
- Paolo Procacci Foundation, Via Tacito 7, 00193, Rome, Italy.
- World Institute of Pain, Winston-Salem, NC, USA.
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