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Whitehouse T, Hossain A, Perkins GD, Gordon AC, Bion J, Young D, McAuley D, Singer M, Lord J, Gates S, Veenith T, MacCallum NS, Yeung J, Innes R, Welters I, Boota N, Skilton E, Ghuman B, Hill M, Regan SE, Mistry D, Lall R. Landiolol and Organ Failure in Patients With Septic Shock: The STRESS-L Randomized Clinical Trial. JAMA 2023; 330:1641-1652. [PMID: 37877587 PMCID: PMC10600724 DOI: 10.1001/jama.2023.20134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 09/18/2023] [Indexed: 10/26/2023]
Abstract
Importance Patients with septic shock undergo adrenergic stress, which affects cardiac, immune, inflammatory, and metabolic pathways. β-Blockade may attenuate the adverse effects of catecholamine exposure and has been associated with reduced mortality. Objectives To assess the efficacy and safety of landiolol in patients with tachycardia and established septic shock requiring prolonged (>24 hours) vasopressor support. Design, Setting, and Participants An open-label, multicenter, randomized trial involving 126 adults (≥18 years) with tachycardia (heart rate ≥95/min) and established septic shock treated for at least 24 hours with continuous norepinephrine (≥0.1 μg/kg/min) in 40 UK National Health Service intensive care units. The trial ran from April 2018 to December 2021, with early termination in December 2021 due to a signal of possible harm. Intervention Sixty-three patients were randomized to receive standard care and 63 to receive landiolol infusion. Main Outcomes and Measures The primary outcome was the mean Sequential Organ Failure Assessment (SOFA) score from randomization through 14 days. Secondary outcomes included mortality at days 28 and 90 and the number of adverse events in each group. Results The trial was stopped prematurely on the advice of the independent data monitoring committee because it was unlikely to demonstrate benefit and because of possible harm. Of a planned 340 participants, 126 (37%) were enrolled (mean age, 55.6 years [95% CI, 52.7 to 58.5 years]; 58.7% male). The mean (SD) SOFA score in the landiolol group was 8.8 (3.9) compared with 8.1 (3.2) in the standard care group (mean difference [MD], 0.75 [95% CI, -0.49 to 2.0]; P = .24). Mortality at day 28 after randomization in the landiolol group was 37.1% (23 of 62) and 25.4% (16 of 63) in the standard care group (absolute difference, 11.7% [95% CI, -4.4% to 27.8%]; P = .16). Mortality at day 90 after randomization was 43.5% (27 of 62) in the landiolol group and 28.6% (18 of 63) in the standard care group (absolute difference, 15% [95% CI, -1.7% to 31.6%]; P = .08). There were no differences in the number of patients having at least one adverse event. Conclusion and Relevance Among patients with septic shock with tachycardia and treated with norepinephrine for more than 24 hours, an infusion of landiolol did not reduce organ failure measured by the SOFA score over 14 days from randomization. These results do not support the use of landiolol for managing tachycardia among patients treated with norepinephrine for established septic shock. Trial Registration EU Clinical Trials Register Eudra CT: 2017-001785-14; isrctn.org Identifier: ISRCTN12600919.
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Affiliation(s)
- Tony Whitehouse
- University Hospitals of Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, United Kingdom
- Institute of Inflammation and Ageing, University of Birmingham, United Kingdom
| | - Anower Hossain
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
| | - Gavin D. Perkins
- University Hospitals of Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, United Kingdom
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
| | - Anthony C. Gordon
- Division of Anaesthetics, Pain Medicine & Intensive Care, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Julian Bion
- University Hospitals of Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, United Kingdom
- Institute of Clinical Sciences, University of Birmingham, United Kingdom
| | - Duncan Young
- Kadoorie Centre for Critical Care Research, Nuffield Division of Anaesthesia, University of Oxford, Oxford, United Kingdom
| | - Danny McAuley
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, United Kingdom
- The Wellcome Wolfson Institute for Experimental Medicine, Queens University Belfast, Belfast, United Kingdom
| | - Mervyn Singer
- Centre for Intensive Care Medicine, Department of Medicine and Wolfson Institute for Biomedical Research, University College, London, United Kingdom
| | - Janet Lord
- Institute of Inflammation and Ageing, University of Birmingham, United Kingdom
| | - Simon Gates
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
| | - Tonny Veenith
- University Hospitals of Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, United Kingdom
- Institute of Inflammation and Ageing, University of Birmingham, United Kingdom
| | - Niall S. MacCallum
- University College London Hospitals NHS Foundation Trust, Gower Street, London, United Kingdom
| | - Joyce Yeung
- University Hospitals of Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, United Kingdom
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
| | - Richard Innes
- Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, United Kingdom
| | | | - Nafisa Boota
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
| | - Emma Skilton
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
| | - Belinder Ghuman
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
| | - Maddy Hill
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
| | - Scott E. Regan
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
| | - Dipesh Mistry
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
| | - Ranjit Lall
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
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Kumar S, Malviya D, Tripathi M, Rai S, Nath SS, Tripathi SS, Mishra S. Exploring the Impact of Prior Beta-Blocker and Calcium Channel Blocker Usage on Clinical Outcomes in Critically Ill Patients With Sepsis: An Observational Study. Cureus 2023; 15:e46169. [PMID: 37905278 PMCID: PMC10613320 DOI: 10.7759/cureus.46169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2023] [Indexed: 11/02/2023] Open
Abstract
Background Sepsis is associated with increased Ca++ levels in many cell types that can cause cytotoxicity and cell death through multiple mechanisms. In patients with sepsis, limiting beta-adrenergic stimulation may also be beneficial. The intense adrenergic stimulation of sepsis results in cardiac and extra-cardiac effects. In the intensive care unit (ICU), the question of whether to continue calcium channel blockers (CCBs) and beta-blockers in patients with sepsis who were using these medications before ICU admission is of significant concern. Methodology In this prospective observational study, we have included 114 patients who met the inclusion criteria of being diagnosed as having sepsis, aged 18 to 65 years, and expected to stay in the ICU for more than 72 hours. These patients were divided into three groups: group 1 consisted of patients taking CCBs before admission, group 2 included those taking beta-blockers before admission, and group 3 served as the control group, comprising patients who had not taken either of these medications before admission. Disease severity in the ICU was assessed and documented by the Sequential Organ Failure Assessment (SOFA) score. Clinical outcomes among three groups were compared regarding the need for vasopressor support, serum procalcitonin (PCT), serum lactate, serum quantitative C-reactive protein (qCRP), SOFA score, and 28 days mortality. Parametric data were expressed as mean ± standard deviation. The Kruskal-Wallis test was used to analyze parametric data between the two groups and among three groups. Results Mortality was found lower in group 1 (21.05%) and group 2 (26.31%) than in group 3 (47.36%), and this association was found to be statistically significant (P = 0.033). We also found a significant difference in mortality between groups 1 and 3 (P = 0.015) and no significant difference between groups 2 and 3 (P = 0.057). Mortality was found to be significantly associated with high SOFA scores on days 1, 3, and 7. Conclusions From the aforementioned results, we concluded that the mortality rate in patients with sepsis was improved when they were pretreated with beta-blockers or CCBs before admission to the ICU and that medication should be continued if not contraindicated in the ICU course.
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Affiliation(s)
- Sachin Kumar
- Department of Anaesthesiology, Rama Medical College Hospital and Research Centre, Kanpur, Kanpur, IND
| | - Deepak Malviya
- Department of Anaesthesia and Critical Care, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, IND
| | - Manoj Tripathi
- Department of Anaesthesia and Critical Care, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, IND
| | - Sujeet Rai
- Department of Anaesthesia and Critical Care, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, IND
| | - Soumya S Nath
- Department of Anaesthesia and Critical Care, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, IND
| | - Shiv Shanker Tripathi
- Department of Emergency Medicine, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, IND
| | - Smarika Mishra
- Department of Anaesthesia and Critical Care, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, IND
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Wang J, Gao X, He Z, Wang J, Xu G, Li T. Evaluating the effects of Esmolol on cardiac function in patients with Septic cardiomyopathy by Speck-tracking echocardiography-a randomized controlled trial. BMC Anesthesiol 2023; 23:51. [PMID: 36765286 PMCID: PMC9912519 DOI: 10.1186/s12871-023-01983-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 01/10/2023] [Indexed: 02/12/2023] Open
Abstract
BACKGROUND Esmolol as one treatment of sepsis induced cardiomyopathy (SIC) is still controversial. The objective of this study is to evaluate cardiac function after reducing heart rate by Esmolol in patients with SIC using speck-tracking echocardiography. METHODS This study was a single-center, prospective, and randomized controlled study. A total of 100 SIC patients with a heart rate more than 100/min, admitted to the Intensive Care Department of Tianjin Third Central Hospital from March 1, 2020 to September 30, 2021, were selected as the research subjects. They were randomly divided into the Esmolol group (Group E) and the conventional treatment group (Group C), each with 50 cases. The target heart rate of patients in Group E was controlled between 80/min and 100/min. Speck-tracking echocardiography (STE) and pulse indicating continuous cardiac output monitoring (PICCO) were performed in both groups at 1 h, 24 h, 48 h, 72 h, 96 h and 7 d after admission, with data concerning left ventricular global longitudinal strain (GLS), left ventricular ejection fraction (LVEF) and global ejection fraction (GEF), left ventricular systolic force index (dP/dtmx) were obtained, respectively. Hemodynamics and other safety indicators were monitored throughout the whole process. These subjects were followed up to 90 d, with their mortality recorded at Day 28 and Day 90, respectively. Statistical analyses were performed using SPSS version 21. RESULTS With 24 h of Esmolol, all patients in Group E achieved the target heart rate, and there was no deterioration of GLS, or adverse events. However, compared with those in Group C, their GLS, GEF and dP/dtmx were increased, and the difference was statistically significant (P > 0.05). Compared with patients in Group C, those in Group E had lower short-term mortality, and logistic regression analysis also suggested that Esmolol improved patient outcomes. CONCLUSION In SIC patients, the application of Esmolol to lower heart rate decreased their short-term mortality while not making any impairment on the myocardial contractility. TRIAL REGISTRATION Chinese Clinical Trial Registry, ChiCTR2100047513. Registered June 20, 2021- Retrospectively registered, http://www.chictr.org.cn/index.aspx . The study protocol followed the CONSORT guidelines. The study protocol was performed in the relevant guidelines.
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Affiliation(s)
- Junyi Wang
- grid.265021.20000 0000 9792 1228The Third Central Clinical College of Tianjin Medical University, Tianjin, 300170 China ,The Third Central Hospital of Tianjin, 83 Jintang Road, Hedong District, Tianjin, 300170 China ,grid.417032.30000 0004 1798 6216Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Artificial Cell Engineering Technology Research Center, Tianjin, China ,grid.417032.30000 0004 1798 6216Tianjin Institute of Hepatobiliary Disease, Tianjin, China
| | - Xinjing Gao
- The Third Central Hospital of Tianjin, 83 Jintang Road, Hedong District, Tianjin, 300170 China ,grid.417032.30000 0004 1798 6216Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Artificial Cell Engineering Technology Research Center, Tianjin, China ,grid.417032.30000 0004 1798 6216Tianjin Institute of Hepatobiliary Disease, Tianjin, China
| | - Zhengzhong He
- The Third Central Hospital of Tianjin, 83 Jintang Road, Hedong District, Tianjin, 300170 China ,grid.417032.30000 0004 1798 6216Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Artificial Cell Engineering Technology Research Center, Tianjin, China ,grid.417032.30000 0004 1798 6216Tianjin Institute of Hepatobiliary Disease, Tianjin, China
| | - Jinxiang Wang
- grid.33763.320000 0004 1761 2484Wenzhou Safety (Emergency) Institute of Tianjin University, Wenzhou 325026 Zhejiang, People’s Republic of China ,grid.412645.00000 0004 1757 9434Department of Emergency Medicine, Tianjin Medical University General Hospital, Tianjin, 300052 People’s Republic of China
| | - Guowu Xu
- grid.33763.320000 0004 1761 2484Wenzhou Safety (Emergency) Institute of Tianjin University, Wenzhou 325026 Zhejiang, People’s Republic of China ,grid.412645.00000 0004 1757 9434Department of Emergency Medicine, Tianjin Medical University General Hospital, Tianjin, 300052 People’s Republic of China
| | - Tong Li
- The Third Central Hospital of Tianjin, 83 Jintang Road, Hedong District, Tianjin, 300170, China. .,Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Artificial Cell Engineering Technology Research Center, Tianjin, China. .,Tianjin Institute of Hepatobiliary Disease, Tianjin, China.
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Geevarghese M, Patel K, Gulati A, Ranjan AK. Role of adrenergic receptors in shock. Front Physiol 2023; 14:1094591. [PMID: 36726848 PMCID: PMC9885157 DOI: 10.3389/fphys.2023.1094591] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 01/04/2023] [Indexed: 01/18/2023] Open
Abstract
Shock is a severe, life-threatening medical condition with a high mortality rate worldwide. All four major categories of shock (along with their various subtypes)-hypovolemic, distributive, cardiogenic, and obstructive, involve a dramatic mismatch between oxygen supply and demand, and share standard features of decreased cardiac output, reduced blood pressure, and overall hypoperfusion. Immediate and appropriate intervention is required regardless of shock type, as a delay can result in cellular dysfunction, irreversible multiple organ failure, and death. Studies have shown that dysfunction and downregulation of adrenergic receptors (ARs) are often implicated in these shock conditions; for example, their density is shown to be decreased in hypovolemic and cardiogenic shock, while their reduced signaling in the brain and vasculature decrease blood perfusion and oxygen supply. There are two main categories of ARs, α, and β, each with its subtypes and distributions. Our group has demonstrated that a dose of .02 mg/kg body wt of centhaquine (CQ) specifically activates α2B ARs on venous circulation along with the central α2A ARs after hypovolemic/hemorrhagic shock. Activating these receptors by CQ increases cardiac output (CO) and reduces systemic vascular resistance (SVR), with a net increase in blood pressure and tissue perfusion. The clinical trials of CQ conducted by Pharmazz Inc. in India have demonstrated significantly improved survival in shock patients. CQ improved blood pressure and shock index, indicating better blood circulation, and reduced lactate levels in the blood compared to in-use standard resuscitative agents. After successful clinical trials, CQ is being marketed as a drug (Lyfaquin®) for hypovolemic/hemorrhagic shock in India, and United States FDA has approved the phase III IND application. It is anticipated that the phase III trial in the United States will begin in 2023. Thus, we have demonstrated that α2 ARs could be suitable targets for treating or managing hypovolemic/hemorrhagic shock. Further understanding of ARs in shock would help find new potential pharmacological targets.
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Affiliation(s)
- Mathew Geevarghese
- Midwestern University Chicago College of Osteopathic Medicine, Downers Grove, IL, United States
| | - Krishna Patel
- Midwestern University Chicago College of Osteopathic Medicine, Downers Grove, IL, United States
| | - Anil Gulati
- Pharmazz Inc., Research and Development, Willowbrook, IL, United States,Department of Bioengineering, The University of Illinois at Chicago, Chicago, IL, United States,Midwestern University College of Pharmacy Downers Grove, Downers Grove, IL, United States,*Correspondence: Anil Gulati, ; Amaresh K. Ranjan,
| | - Amaresh K. Ranjan
- Midwestern University College of Pharmacy Downers Grove, Downers Grove, IL, United States,*Correspondence: Anil Gulati, ; Amaresh K. Ranjan,
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Heliste M, Pettilä V, Berger D, Jakob SM, Wilkman E. Beta-blocker treatment in the critically ill: a systematic review and meta-analysis. Ann Med 2022; 54:1994-2010. [PMID: 35838226 PMCID: PMC9291706 DOI: 10.1080/07853890.2022.2098376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Critical illness may lead to activation of the sympathetic system. The sympathetic stimulation may be further increased by exogenous catecholamines, such as vasopressors and inotropes. Excessive adrenergic stress has been associated with organ dysfunction and higher mortality. β-Blockers may reduce the adrenergic burden, but they may also compromise perfusion to vital organs thus worsening organ dysfunction. To assess the effect of treatment with β-blockers in critically ill adults, we conducted a systematic review and meta-analysis of randomized controlled trials. MATERIALS AND METHODS We conducted a search from three major databases: Ovid Medline, the Cochrane Central Register for Controlled Trials and Scopus database. Two independent reviewers screened, selected, and assessed the included articles according to prespecified eligibility criteria. We assessed risk of bias of eligible articles according to the Cochrane guidelines. Quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. RESULTS Sixteen randomized controlled trials comprising 2410 critically ill patients were included in the final review. A meta-analysis of 11 trials including 2103 patients showed a significant reduction in mortality in patients treated with β-blockers compared to control (risk ratio 0.65, 95%CI 0.53-0.79; p < .0001). There was no significant difference in mean arterial pressure or vasopressor load. Quality of life, biventricular ejection fraction, blood lactate levels, cardiac biomarkers and mitochondrial function could not be included in meta-analysis due to heterogenous reporting of outcomes. CONCLUSIONS In this systematic review we found that β-blocker treatment reduced mortality in critical illness. Use of β-blockers in critical illness thus appears safe after initial hemodynamic stabilization. High-quality RCT's are needed to answer the questions concerning optimal target group of patients, timing of β-blocker treatment, choice of β-blocker, and choice of physiological and hemodynamic parameters to target during β-blocker treatment in critical illness.KEY MESSAGESA potential outcome benefit of β-blocker treatment in critical illness exists according to the current review and meta-analysis. Administration of β-blockers to resuscitated patients in the ICU seems safe in terms of hemodynamic stability and outcome, even during concomitant vasopressor administration. However, further studies, preferably large RCTs on β-blocker treatment in the critically ill are needed to answer the questions concerning timing and choice of β-blocker, patient selection, and optimal hemodynamic targets.
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Affiliation(s)
- Maria Heliste
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ville Pettilä
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - David Berger
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stephan M Jakob
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Erika Wilkman
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Kansal A, Ong WJD, Dhanvijay S, Siosana ATP, Padillo LM, Tan CK, Gulati Kansal M, Khan FA. Comparison of ROX index (SpO2/FIO2 ratio/respiratory rate) with a modified dynamic index incorporating PaO2/FIO2 ratio and heart rate to predict high flow nasal cannula outcomes among patients with acute respiratory failure: a single centre retrospective study. BMC Pulm Med 2022; 22:350. [PMID: 36114516 PMCID: PMC9482300 DOI: 10.1186/s12890-022-02121-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 08/23/2022] [Indexed: 11/13/2022] Open
Abstract
Background High flow nasal cannula (HFNC) is increasingly being used to support patients with acute respiratory failure (ARF) and to avoid need for intubation. However, almost one third of the patients do not respond and require escalation of respiratory support. Previously, ROX index (SpO2/FIO2 [SF] ratio/respiratory rate) has been validated among pneumonia patients to facilitate early recognition of patients likely to fail HFNC and therefore, benefit from timely interventions. However, it has been postulated that incorporation of PaO2/FIO2 (PF) ratio from arterial blood gas (ABG) analysis may better predict the outcome of HFNC compared to indices that utilizes SF ratio. Similarly, heart rate increase after HFNC therapy initiation has been found to be associated with HFNC failure. Therefore, we aimed to compare ROX index with a new modified index to predict HFNC outcomes among ARF patients. Materials and methods This single centre 2-year retrospective study included ARF patients of varying etiologies treated with HFNC. The modified index incorporated heart rate and substituted PF ratio for SF ratio in addition to respiratory rate. We named the index POX-HR and calculated Delta POX-HR index as the difference pre- and post-HFNC initiation POX-HR. We also recorded ROX index at the time when post-HFNC initiation ABG was done (‘post-HFNC initiation ROX’) and calculated Delta ROX. HFNC success was defined as no need of escalation of respiratory support or discharged to ward within 48 h of HFNC initiation, or successful wean off HFNC for at least 12 h. Evaluation was performed using area under the receiver operating characteristic curve (AUROC) and cut-offs assessed for prediction of HFNC outcomes. Results One hundred eleven patients were initiated on HFNC for ARF, of whom 72 patients (64.9%) had HFNC success. Patients with HFNC failure had significantly lower values for all the indices. At median of 3.33 h (IQR 1.48–7.24 h), Delta POX-HR demonstrated the best prediction accuracy (AUROC 0.813, 95% CI 0.726–0.900). A Delta POX-HR > 0.1 was significantly associated with a lower risk of HFNC failure. Conclusions Our proposed modified dynamic index (Delta POX-HR) may facilitate early and accurate prediction of HFNC outcomes compared to ROX index among ARF patients of varied etiologies.
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Zhang J, Chen C, Liu Y, Yang Y, Yang X, Yang J. Benefits of esmolol in adults with sepsis and septic shock: An updated meta-analysis of randomized controlled trials. Medicine (Baltimore) 2022; 101:e29820. [PMID: 35801730 PMCID: PMC9259117 DOI: 10.1097/md.0000000000029820] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Sepsis affects millions of patients annually, resulting in substantial health and economic burdens globally. The role of esmolol potentially plays in the treatment of sepsis and septic shock in adult patients remains controversial. METHODS We undertook a systematic search of PubMed, EMBASE, and Cochrane Central Register of Controlled Trials databases from their inception to May 12, 2022, for randomized controlled trials that evaluated the efficacy of esmolol for sepsis and septic shock. A random-effects meta-analysis was performed. Two investigators independently screened articles, extracted data, and assessed the quality of included studies. RESULTS Eight studies from 7 randomized controlled trials were included in our meta-analysis of 503 patients with sepsis and/or septic shock. Compared with standard treatment, esmolol significantly decreased 28-day mortality (risk ratio 0.68, 95% confidence interval [CI] 0.52-0.88; P = .004), heart rate (standardized mean difference [SMD] -1.83, 95% CI -2.95 to -0.70, P = .001), tumor necrosis factor-a (SMD -0.48, 95% CI -0.94 to -0.02, P = .04), and the troponin I level (SMD -0.59, 95% CI -1.02 to -0.16, P = .008) 24 hours after treatment. No significant effect was found in terms of length of intensive care unit stay; mean arterial pressure, lactic acid, central venous pressure, or central venous oxygen saturation, interleukin 6, or white blood cell levels; stroke volume index; or the PaO2/FiO2 ratio. CONCLUSIONS Esmolol treatment may be safe and effective in decreasing 28-day mortality, controlling heart rate, and providing cardioprotective function, but has no effect on lung injury in patients with sepsis or septic shock after early fluid resuscitation. Improvement in cardiac function may be related to changes in serum inflammatory mediators. No significant adverse effects on tissue perfusion and oxygen utilization were observed.
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Affiliation(s)
- Jing Zhang
- Department of Intensive Care Unit, Chongqing General Hospital, University of Chinese Academy of Sciences, Chongqing, China
| | - Chun Chen
- Department of Nephrology, Chongqing General Hospital, University of Chinese Academy of Sciences, Chongqing, China
| | - Yi Liu
- Department of Intensive Care Unit, Chongqing General Hospital, University of Chinese Academy of Sciences, Chongqing, China
| | - Yi Yang
- Department of Intensive Care Unit, Chongqing General Hospital, University of Chinese Academy of Sciences, Chongqing, China
| | - Xiaolei Yang
- Department of Intensive Care Unit, Chongqing General Hospital, University of Chinese Academy of Sciences, Chongqing, China
| | - Jin Yang
- Department of Intensive Care Unit, Chongqing General Hospital, University of Chinese Academy of Sciences, Chongqing, China
- * Correspondence: Jin Yang, MD, Department of Intensive Care Unit, Chongqing General Hospital, University of Chinese Academy of Sciences, Chongqing 401147, China (e-mail: )
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8
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[Heart rate control in shock]. Med Klin Intensivmed Notfmed 2022; 117:200-205. [PMID: 35298671 DOI: 10.1007/s00063-022-00908-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 02/14/2022] [Indexed: 10/18/2022]
Abstract
Heart rate is well established in the diagnosis of shock; however, the mechanisms regulating heart rate, systemic resistance and blood pressure remain unclear. The concept of heart rate control in shock-related tachycardia has been known for about 50 years. Elevated heart rates in septic shock have been identified as an indicator of increasingly inefficient hemodynamics, worsening perfusion and organ function as well as of an unfavourable prognosis. Many drugs used for heart rate control also lower blood pressure. The challenge of this therapeutic concept is achieving optimal heart rate control without provoking critical hypotension. Only in recent years has the development of highly cardioselective, short- and ultrashort-acting β‑blockers such as esmolol and landiolol made it possible to prove the feasibility and usefulness of heart rate control in certain types of shock.
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Bruning R, Dykes H, Jones TW, Wayne NB, Sikora Newsome A. Beta-Adrenergic Blockade in Critical Illness. Front Pharmacol 2021; 12:735841. [PMID: 34721025 PMCID: PMC8554196 DOI: 10.3389/fphar.2021.735841] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 09/27/2021] [Indexed: 12/31/2022] Open
Abstract
Catecholamine upregulation is a core pathophysiological feature in critical illness. Sustained catecholamine β-adrenergic induction produces adverse effects relevant to critical illness management. β-blockers (βB) have proposed roles in various critically ill disease states, including sepsis, trauma, burns, and cardiac arrest. Mounting evidence suggests βB improve hemodynamic and metabolic parameters culminating in decreased burn healing time, reduced mortality in traumatic brain injury, and improved neurologic outcomes following cardiac arrest. In sepsis, βB appear hemodynamically benign after acute resuscitation and may augment cardiac function. The emergence of ultra-rapid βB provides new territory for βB, and early data suggest significant improvements in mitigating atrial fibrillation in persistently tachycardic septic patients. This review summarizes the evidence regarding the pharmacotherapeutic role of βB on relevant pathophysiology and clinical outcomes in various types of critical illness.
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Affiliation(s)
- Rebecca Bruning
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Augusta, GA, United States
| | - Hannah Dykes
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Augusta, GA, United States
| | - Timothy W Jones
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Augusta, GA, United States
| | - Nathaniel B Wayne
- Department of Pharmacy, Augusta University Medical Center, Augusta, GA, United States
| | - Andrea Sikora Newsome
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Augusta, GA, United States
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10
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Patel JS, Colon Hidalgo D, Capistrano I, Mancl E, Rech MA. Antihypertensive Medications Prior to Shock Onset Do Not Impact Initial Vasopressor Requirements in Patients With Shock. J Pharm Pract 2021; 36:342-349. [PMID: 34601987 DOI: 10.1177/08971900211048623] [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: 11/16/2022]
Abstract
Purpose: The effect of the use of antihypertensive agents in patients prior to the development of shock is unclear. The purpose of this study was to determine the impact of antihypertensive agents on vasopressor dose and duration in shock. Materials and Methods: This retrospective, single-center study included patients with shock who received at least one vasopressor for at least 24 hours after shock onset from January 1 to June 30, 2017. Patients taking an antihypertensive agent(s) were compared to those who were not. The primary outcome was the number of vasopressor-free hours at 72 hours. Secondary outcomes included maximum and cumulative vasopressor doses, intensive care unit length of stay, and 30-day mortality. Results: One hundred and sixty-eight patients were included and 99 (59%) were on antihypertensives. Distributive shock was the most common type of shock (75.5%) and more patients taking antihypertensives had hypertension, coronary artery disease, and dyslipidemia at baseline. There was no difference in the number of vasopressor-free hours at 72 hours between patients taking an antihypertensive medication(s) and the control group (2 hours vs 1 hour; P = .11). No difference was found between any of the secondary outcomes. Conclusion: Patients taking antihypertensive agents prior to shock onset did not require increased vasopressor doses or duration.
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Affiliation(s)
- Jaimini S Patel
- Department of Pharmacy, Cleveland Clinic Akron General Medical Center, OH, USA
| | | | - Irene Capistrano
- Department of Pharmacy, 25815Loyola University Medical Center, IL, USA
| | - Erin Mancl
- Department of Pharmacy, 25815Loyola University Medical Center, IL, USA
| | - Megan A Rech
- Department of Pharmacy, 25815Loyola University Medical Center, IL, USA.,Department of Emergency Medicine, Stritch School of Medicine, Loyola University Chicago, IL, USA
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11
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Petitjeans F, Geloen A, Pichot C, Leroy S, Ghignone M, Quintin L. Is the Sympathetic System Detrimental in the Setting of Septic Shock, with Antihypertensive Agents as a Counterintuitive Approach? A Clinical Proposition. J Clin Med 2021; 10:4569. [PMID: 34640590 PMCID: PMC8509206 DOI: 10.3390/jcm10194569] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 08/05/2021] [Accepted: 09/07/2021] [Indexed: 12/14/2022] Open
Abstract
Mortality in the setting of septic shock varies between 20% and 100%. Refractory septic shock leads to early circulatory failure and carries the worst prognosis. The pathophysiology is poorly understood despite studies of the microcirculatory defects and the immuno-paralysis. The acute circulatory distress is treated with volume expansion, administration of vasopressors (usually noradrenaline: NA), and inotropes. Ventilation and anti-infectious strategy shall not be discussed here. When circulation is considered, the literature is segregated between interventions directed to the systemic circulation vs. interventions directed to the micro-circulation. Our thesis is that, after stabilization of the acute cardioventilatory distress, the prolonged sympathetic hyperactivity is detrimental in the setting of septic shock. Our hypothesis is that the sympathetic hyperactivity observed in septic shock being normalized towards baseline activity will improve the microcirculation by recoupling the capillaries and the systemic circulation. Therefore, counterintuitively, antihypertensive agents such as beta-blockers or alpha-2 adrenergic agonists (clonidine, dexmedetomidine) are useful. They would reduce the noradrenaline requirements. Adjuncts (vitamins, steroids, NO donors/inhibitors, etc.) proposed to normalize the sepsis-evoked vasodilation are not reviewed. This itemized approach (systemic vs. microcirculation) requires physiological and epidemiological studies to look for reduced mortality.
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Affiliation(s)
- Fabrice Petitjeans
- Critical Care, Hôpital d’Instruction des Armées Desgenettes, 69003 Lyon, France;
| | - Alain Geloen
- UMR Ecologie Microbienne Lyon (LEM), University of Lyon, 69100 Villeurbanne, France;
| | - Cyrille Pichot
- Critical Care, Hôpital Louis Pasteur, 39108 Dole, France;
| | | | - Marco Ghignone
- Critical Care, JF Kennedy Hospital North Campus, West Palm Beach, FL 33407, USA;
| | - Luc Quintin
- Critical Care, Hôpital d’Instruction des Armées Desgenettes, 69003 Lyon, France;
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12
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Hemodynamic Impact of Cardiovascular Antihypertensive Medications in Patients With Sepsis-Related Acute Circulatory Failure. Shock 2021; 54:315-320. [PMID: 32080062 DOI: 10.1097/shk.0000000000001524] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Impact of prior cardiovascular antihypertensive medication during the initial phase of septic shock in terms of catecholamine requirements and mortality has been poorly investigated and remains unclear. OBJECTIVES To investigate the association between chronic prescription of cardiovascular antihypertensive medication prior to intensive care unit (ICU) admission, catecholamine requirement, and mortality in patients with septic shock. METHODS We included all consecutive patients diagnosed with septic shock within the first 24 h of ICU admission, defined as a microbiologically proven or clinically suspected infection, associated with acute circulatory failure requiring vasopressors despite adequate fluid filling. Prior cardiovascular antihypertensive medication was defined as the chronic use of betablockers (BB), calcium channel blockers (CCB), angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blockers (ARB). ICU mortality was investigated using multivariate competitive risk analysis. RESULTS Among 735 patients admitted for septic shock between 2008 and 2016, 46.9% received prior cardiovascular antihypertensive medication. Prior cardiovascular antihypertensive therapy was not associated with increased norepinephrine requirements during the first 24 h (median = 0.28 μg/kg/min in patients previously treated vs. 0.26 μg/kg/min). Prior cardiovascular antihypertensive medication was not associated with a higher risk of ICU mortality after adjustment (cause-specific hazard = 1.28, 95% confidence interval [0.98-1.66], P = 0.06). Subgroups analyses for BB, CCB, and ACEi/ARB using propensity score analyses retrieved similar results. CONCLUSION In patients admitted with septic shock, prior cardiovascular antihypertensive medication seems to have limited impact on initial hemodynamic failure and catecholamine requirement.
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13
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Ultrashort-Acting β-Blockers: Are We on the Right Path? Chest 2021; 159:2139-2140. [PMID: 34099120 DOI: 10.1016/j.chest.2021.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 02/05/2021] [Indexed: 11/23/2022] Open
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14
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Tan K, Harazim M, Simpson A, Tan YC, Gunawan G, Robledo KP, Whitehead C, Tang B, Mclean A, Nalos M. Association Between Premorbid Beta-Blocker Exposure and Sepsis Outcomes-The Beta-Blockers in European and Australian/American Septic Patients (BEAST) Study. Crit Care Med 2021; 49:1493-1503. [PMID: 33938711 DOI: 10.1097/ccm.0000000000005034] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To examine the effect of premorbid β-blocker exposure on mortality and organ dysfunction in sepsis. DESIGN Retrospective observational study. SETTING ICUs in Australia, the Czech Republic, and the United States. PATIENTS Total of 4,086 critical care patients above 18 years old with sepsis between January 2014 and December 2018. INTERVENTION Premorbid beta-blocker exposure. MEASUREMENTS AND MAIN RESULTS One thousand five hundred fifty-six patients (38%) with premorbid β-blocker exposure were identified. Overall ICU mortality rate was 15.1%. In adjusted models, premorbid β-blocker exposure was associated with decreased ICU (adjusted odds ratio, 0.80; 95% CI, 0.66-0.97; p = 0.025) and hospital (adjusted odds ratio, 0.83; 95% CI, 0.71-0.99; p = 0.033) mortality. The risk reduction in ICU mortality of 16% was significant (hazard ratio, 0.84, 95% CI, 0.71-0.99; p = 0.037). In particular, exposure to noncardioselective β-blocker before septic episode was associated with decreased mortality. Sequential Organ Failure Assessment score analysis showed that premorbid β-blocker exposure had potential benefits in reducing respiratory and neurologic dysfunction. CONCLUSIONS This study suggests that β-blocker exposure prior to sepsis, especially to noncardioselective β blockers, may be associated with better outcome. The findings suggest prospective evaluation of β-blocker use in the management of sepsis.
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Affiliation(s)
- Kaiquan Tan
- 1 Nepean Clinical School, Sydney Medical School, University of Sydney, Sydney, NSW, Australia. 2 Medical Intensive Care Unit, University Hospital and Biomedicine Centre, Pilsen, Charles University Prague, Czech Republic. 3 Department of Intensive Care Medicine, Nepean Hospital, Kingswood, NSW, Australia. 4 Department of Computer Science, Yale University, New Haven, CT. 5 Medistra Hospital, Jakarta, Indonesia. 6 NHMRC Clinical Trials Centre, The University of Sydney, Sydney, NSW, Australia. 7 Centre for immunology and allergy research, Westmead Millennium Institute, Westmead, NSW, Australia
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15
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Donovan K, Shah A, Day J, McKechnie SR. Adjunctive treatments for the management of septic shock - a narrative review of the current evidence. Anaesthesia 2021; 76:1245-1258. [PMID: 33421029 DOI: 10.1111/anae.15369] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2020] [Indexed: 12/13/2022]
Abstract
Septic shock is a leading cause of death and morbidity worldwide. The cornerstones of management include prompt identification of sepsis, early initiation of antibiotic therapy, adequate fluid resuscitation and organ support. Over the past two decades, there have been considerable improvements in our understanding of the pathophysiology of sepsis and the host response, including regulation of inflammation, endothelial disruption and impaired immunity. This has offered opportunities for innovative adjunctive treatments such as vitamin C, corticosteroids and beta-blockers. Some of these approaches have shown promising results in early phase trials in humans, while others, such as corticosteroids, have been tested in large, international, multicentre randomised controlled trials. Contemporary guidelines make a weak recommendation for the use of corticosteroids to reduce mortality in sepsis and septic shock. Vitamin C, despite showing initial promise in observational studies, has so far not been shown to be clinically effective in randomised trials. Beta-blocker therapy may have beneficial cardiac and non-cardiac effects in septic shock, but there is currently insufficient evidence to recommend their use for this condition. The results of ongoing randomised trials are awaited. Crucial to reducing heterogeneity in the trials of new sepsis treatments will be the concept of enrichment, which refers to the purposive selection of patients with clinical and biological characteristics that are likely to be responsive to the intervention being tested.
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Affiliation(s)
- K Donovan
- Adult Intensive Care Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Adult Intensive Care Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - A Shah
- Adult Intensive Care Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - J Day
- Adult Intensive Care Unit and Nuffield Department of Anaesthesia, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - S R McKechnie
- Adult Intensive Care Unit and Nuffield Department of Anaesthesia, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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16
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Rakhit S, Nordness MF, Lombardo SR, Cook M, Smith L, Patel MB. Management and Challenges of Severe Traumatic Brain Injury. Semin Respir Crit Care Med 2020; 42:127-144. [PMID: 32916746 DOI: 10.1055/s-0040-1716493] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Traumatic brain injury (TBI) is the leading cause of death and disability in trauma patients, and can be classified into mild, moderate, and severe by the Glasgow coma scale (GCS). Prehospital, initial emergency department, and subsequent intensive care unit (ICU) management of severe TBI should focus on avoiding secondary brain injury from hypotension and hypoxia, with appropriate reversal of anticoagulation and surgical evacuation of mass lesions as indicated. Utilizing principles based on the Monro-Kellie doctrine and cerebral perfusion pressure (CPP), a surrogate for cerebral blood flow (CBF) should be maintained by optimizing mean arterial pressure (MAP), through fluids and vasopressors, and/or decreasing intracranial pressure (ICP), through bedside maneuvers, sedation, hyperosmolar therapy, cerebrospinal fluid (CSF) drainage, and, in refractory cases, barbiturate coma or decompressive craniectomy (DC). While controversial, direct ICP monitoring, in conjunction with clinical examination and imaging as indicated, should help guide severe TBI therapy, although new modalities, such as brain tissue oxygen (PbtO2) monitoring, show great promise in providing strategies to optimize CBF. Optimization of the acute care of severe TBI should include recognition and treatment of paroxysmal sympathetic hyperactivity (PSH), early seizure prophylaxis, venous thromboembolism (VTE) prophylaxis, and nutrition optimization. Despite this, severe TBI remains a devastating injury and palliative care principles should be applied early. To better affect the challenging long-term outcomes of severe TBI, more and continued high quality research is required.
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Affiliation(s)
- Shayan Rakhit
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee.,Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mina F Nordness
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee.,Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sarah R Lombardo
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Madison Cook
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee.,Meharry Medical College, Nashville, Tennessee
| | - Laney Smith
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee.,Washington and Lee University, Lexington, Virginia
| | - Mayur B Patel
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee.,Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Neurosurgery and Hearing and Speech Sciences, Vanderbilt Brain Institute, Vanderbilt University Medical Center, Nashville, Tennessee.,Surgical Service, Nashville VA Medical Center, Tennessee Valley Healthcare System, US Department of Veterans Affairs, Nashville, Tennessee.,Geriatric Research, Education, and Clinical Center Service, Nashville VA Medical Center, Tennessee Valley Healthcare System, US Department of Veterans Affairs, Nashville, Tennessee
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17
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Jones TW, Smith SE, Van Tuyl JS, Newsome AS. Sepsis With Preexisting Heart Failure: Management of Confounding Clinical Features. J Intensive Care Med 2020; 36:989-1012. [PMID: 32495686 DOI: 10.1177/0885066620928299] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Preexisting heart failure (HF) in patients with sepsis is associated with worse clinical outcomes. Core sepsis management includes aggressive volume resuscitation followed by vasopressors (and potentially inotropes) if fluid is inadequate to restore perfusion; however, large fluid boluses and vasoactive agents are concerning amid the cardiac dysfunction of HF. This review summarizes evidence regarding the influence of HF on sepsis clinical outcomes, pathophysiologic concerns, resuscitation targets, hemodynamic interventions, and adjunct management (ie, antiarrhythmics, positive pressure ventilatory support, and renal replacement therapy) in patients with sepsis and preexisting HF. Patients with sepsis and preexisting HF receive less fluid during resuscitation; however, evidence suggests traditional fluid resuscitation targets do not increase the risk of adverse events in HF patients with sepsis and likely improve outcomes. Norepinephrine remains the most well-supported vasopressor for patients with sepsis with preexisting HF, while dopamine may induce more cardiac adverse events. Dobutamine should be used cautiously given its generally detrimental effects but may have an application when combined with norepinephrine in patients with low cardiac output. Management of chronic HF medications warrants careful consideration for continuation or discontinuation upon development of sepsis, and β-blockers may be appropriate to continue in the absence of acute hemodynamic decompensation. Optimal management of atrial fibrillation may include β-blockers after acute hemodynamic stabilization as they have also shown independent benefits in sepsis. Positive pressure ventilatory support and renal replacement must be carefully monitored for effects on cardiac function when HF is present.
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Affiliation(s)
- Timothy W Jones
- Department of Clinical and Administrative Pharmacy, 15506University of Georgia College of Pharmacy, Augusta, GA, USA
| | - Susan E Smith
- Department of Clinical and Administrative Pharmacy, 15506University of Georgia College of Pharmacy, Athens, GA, USA
| | - Joseph S Van Tuyl
- Department of Pharmacy Practice, 14408St Louis College of Pharmacy, St Louis, MO, USA
| | - Andrea Sikora Newsome
- Department of Clinical and Administrative Pharmacy, 15506University of Georgia College of Pharmacy, Augusta, GA, USA.,Department of Pharmacy, Augusta University Medical Center, Augusta, GA, USA
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18
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Chen A, Elia N, Dunaiceva J, Rudiger A, Walder B, Bollen Pinto B. Effect of ivabradine on major adverse cardiovascular events and mortality in critically ill patients: a systematic review and meta-analyses of randomised controlled trials with trial sequential analyses. Br J Anaesth 2020; 124:726-738. [PMID: 32147100 DOI: 10.1016/j.bja.2020.01.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 01/08/2020] [Accepted: 01/26/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Ivabradine lowers heart rate (HR) without affecting contractility or vascular tone. It is licensed for HR control in chronic heart diseases. We performed a systematic review and meta-analyses to examine whether ivabradine could decrease major adverse cardiovascular events (MACE) and mortality in critically ill patients. METHODS We searched Medline, Embase, Cochrane Library, and Web of Science for RCTs. Trial quality was assessed using the Cochrane risk of bias tool. Random-effects meta-analyses were performed if at least three trials or 100 patients were available. Results are reported as weighted mean difference (WMD), odds ratio (OR), and 95% confidence intervals (CIs). Trial sequential analyses were performed to estimate the sample size needed to reach definitive conclusions of efficacy or futility. RESULTS We included 13 RCTs (n=1497 patients). We found no evidence of an impact of ivabradine on MACE (three RCTs, 819 patients; OR=0.77; 95% CI, 0.53-1.11) or mortality (10 RCTs, 1356 patients; OR=1.07; 95% CI, 0.63-1.82), but sample sizes were not reached to allow definitive conclusions. Compared with placebo or standard care, ivabradine reduced HR (eight RCTs, 464 patients; WMD, -9.5 beats min-1; 95% CI, -13.3 to -5.8). Risk of bradycardia was not different between ivabradine and control (five RCTs, 434 patients; OR=1.2; 95% CI, 0.60-2.38). Risk of bias was overall high or unclear. CONCLUSIONS Ivabradine reduces HR compared with placebo or standard care. The effect on MACE or mortality in acute care remains unclear. Further RCTs powered to detect changes in clinically relevant outcomes are warranted. CLINICAL TRIAL REGISTRATION Prospero CRD42018086109.
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Affiliation(s)
- Aileen Chen
- Division of Anaesthesiology, Department of Acute Medicine, Geneva University Hospitals, Switzerland; Perioperative Basic, Translational and Clinical Research Group, Division of Anaesthesiology, Geneva University Hospitals, Geneva, Switzerland
| | - Nadia Elia
- Division of Anaesthesiology, Department of Acute Medicine, Geneva University Hospitals, Switzerland; Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Jelena Dunaiceva
- Division of Anaesthesiology, Department of Acute Medicine, Geneva University Hospitals, Switzerland
| | - Alain Rudiger
- Medical Department, Hospital Limmettal, Schlieren, Switzerland
| | - Bernhard Walder
- Division of Anaesthesiology, Department of Acute Medicine, Geneva University Hospitals, Switzerland; Perioperative Basic, Translational and Clinical Research Group, Division of Anaesthesiology, Geneva University Hospitals, Geneva, Switzerland
| | - Bernardo Bollen Pinto
- Division of Anaesthesiology, Department of Acute Medicine, Geneva University Hospitals, Switzerland; Perioperative Basic, Translational and Clinical Research Group, Division of Anaesthesiology, Geneva University Hospitals, Geneva, Switzerland.
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19
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Effect of Antihypertensive Medications on Sepsis-Related Outcomes: A Population-Based Cohort Study. Crit Care Med 2020; 47:e386-e393. [PMID: 30688717 DOI: 10.1097/ccm.0000000000003654] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Although the effect of antihypertensive agents on sepsis has been studied, evidence for survival benefit was limited in the literature. We investigated differences in sepsis-related outcomes depending on the antihypertensive drugs given prior to sepsis in patients with hypertension. DESIGN Population-based cohort study. SETTING Sample cohort Database of the National Health Insurance Service from 2003 to 2013 in South Korea. PATIENTS Patients over 30 years old who were diagnosed with sepsis after receiving hypertension treatment. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Primary outcomes, 30-day and 90-day mortality rates, were analyzed for differences among three representative antihypertensive medications: angiotensin- converting enzyme inhibitors or angiotensin II receptor blockers, calcium channel blockers, and thiazides. In total, 4,549 patients diagnosed with hypertension prior to hospitalization for sepsis were identified. The 30-day mortality was significantly higher among patients who did not receive any medications within 1 month before sepsis (36.8%) than among patients who did (32.0%; p < 0.001). The risk for 90-days mortality was significantly lower in prior angiotensin-converting enzyme inhibitors or angiotensin II receptor blocker users (reference) than in other drug users (odds ratio, 1.27; 95% CI, 1.07-1.52). There was no difference in the risk for 30-day and 90-day mortality depending on whether calcium channel blockers or thiazides were used. Use of calcium channel blockers was associated with a decreased risk for inotropic agent administration, compared with those of angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers (odds ratio, 1.23; 95% CI, 1.05-1.44) and thiazides (odds ratio, 1.33; 95% CI, 1.12-1.58). CONCLUSIONS In patients with sepsis, lower mortality rate was associated with prior use of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers not with use of calcium channel blockers or thiazides. The requirement of inotropic agents was significantly lower in prior use of calcium channel blockers, although the survival benefits were not prominent.
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20
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Chan JZW, Tan JH, Lather KS, Ng AJY, Ong Z, Zou X, Chua MT, Kuan WS. Beta-blockers' effect on Levels of Lactate in patients with suspected sepsis - The BeLLa study. Am J Emerg Med 2019; 38:2574-2579. [PMID: 31902697 DOI: 10.1016/j.ajem.2019.12.046] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Revised: 12/02/2019] [Accepted: 12/23/2019] [Indexed: 01/31/2023] Open
Abstract
OBJECTIVE In the assessment and management of septic patients in the emergency department (ED), serum lactate is often measured to stratify severity to guide decision making. Increased adrenergic drive has been postulated as a contributory factor for hyperlactatemia in sepsis. We aim to prospectively evaluate the effect of chronic beta-blocker use on serum lactate levels in sepsis at initial presentation to the ED. METHODS We conducted a prospective observational study at the ED of a tertiary care academic medical center in Singapore. One hundred and ninety-five ED patients who fulfilled all of the following: (1) age 45 years and above, (2) tympanic temperature ≥ 37.8 °C or clinically suspected to have an infection, and (3) quick Sequential (Sepsis-Related) Organ Failure Assessment (qSOFA) score ≥ 1 were included in the study. Serum venous lactate was sampled within two hours from presentation to the ED. The primary outcome measure was the difference in initial serum venous lactate concentration at presentation to the ED in patients on chronic beta-blockers versus patients without. RESULTS Seventy patients (35.9%) were on long-term beta-blocker therapy. The primary outcome of mean initial serum venous lactate concentration was similar between patients prescribed chronic beta-blocker therapy and patients without (1.78 mmol/L versus 1.70 mmol/L, p = .540). Chronic beta-blocker therapy also did not significantly affect mean initial serum venous lactate concentration across all subgroups of sepsis risk stratification. CONCLUSIONS Long-term beta-blocker therapy did not significantly affect initial serum venous lactate concentration in ED patients with suspected sepsis.
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Affiliation(s)
- Jonathan Zhao Wang Chan
- Department of Emergency Medicine, Woodlands Health Campus, National Healthcare Group, Singapore
| | | | - Kanwar Sudhir Lather
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore; Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Alexander Jet Yue Ng
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore
| | | | - Xiangyu Zou
- Ministry of Health Holdings Pte Ltd, Singapore
| | - Mui Teng Chua
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore; Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
| | - Win Sen Kuan
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore; Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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21
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Ahl R, Matthiessen P, Cao Y, Sjolin G, Ljungqvist O, Mohseni S. The Relationship Between Severe Complications, Beta-Blocker Therapy and Long-Term Survival Following Emergency Surgery for Colon Cancer. World J Surg 2019; 43:2527-2535. [PMID: 31214833 DOI: 10.1007/s00268-019-05058-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Emergency surgery for colon cancer carries significant morbidity, and studies show more than doubled mortality when comparing elective to emergency surgery. The relationship between postoperative complications and survival has been outlined. Beta-blocker therapy has been linked to improved postoperative outcomes. This study aims to assess the impact of postoperative complications on long-term survival following emergency surgery for colon cancer and to determine whether beta-blockade can reduce complications. STUDY DESIGN This cohort study utilized the prospective Swedish Colorectal Cancer Registry to identify adults undergoing emergency colon cancer surgery between 2011 and 2016. Prescription data for preoperative beta-blocker therapy were collected from the national drug registry. Cox regression was used to evaluate the effect of beta-blocker exposure and complications on 1-year mortality, and Poisson regression was used to evaluate beta-blocker exposure in patients with major complications. RESULTS A total of 3139 patients were included with a mean age of 73.1 [12.4] of which 671 (21.4%) were prescribed beta-blockers prior to surgery. Major complications occurred in 375 (11.9%) patients. Those suffering major complications showed a threefold increase in 1-year mortality (adjusted HR = 3.29; 95% CI 2.75-3.94; p < 0.001). Beta-blocker use was linked to a 60% risk reduction in 1-year mortality (adjusted HR = 0.40; 95% CI 0.26-0.62; p < 0.001) but did not show a statistically significant association with reductions in major complications (adjusted IRR = 0.77; 95% CI 0.59-1.00; p = 0.055). CONCLUSION The development of major complications after emergency colon cancer surgery is associated with increased mortality during one year after surgery. Beta-blocker therapy may protect against postoperative complications.
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Affiliation(s)
- Rebecka Ahl
- Department of Surgery, Karolinska University Hospital, Stockholm, Sweden
- School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Peter Matthiessen
- School of Medical Sciences, Örebro University, Örebro, Sweden
- Division of Colorectal Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden
| | - Yang Cao
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Gabriel Sjolin
- School of Medical Sciences, Örebro University, Örebro, Sweden
- Department of Surgery, Örebro University Hospital, Örebro, Sweden
| | - Olle Ljungqvist
- Department of Surgery, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - Shahin Mohseni
- School of Medical Sciences, Örebro University, Örebro, Sweden.
- Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
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22
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Maghami S, Cao Y, Ahl R, Detlofsson E, Matthiessen P, Sarani B, Mohseni S. Beta-blocker Therapy is Associated with Decreased 1-year Mortality After Emergency Laparotomy in Geriatric Patients. Scand J Surg 2019; 110:37-43. [DOI: 10.1177/1457496919877582] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background and Aims: Emergency laparotomy is associated with a great risk of mortality in the elderly. The hyperadrenergic state induced by surgical trauma may play an important role in the pathophysiology of this increased risk. Studies have shown that beta-blocker exposure may be associated with decreased morbidity and mortality in the perioperative period. We aimed to study the effect of beta-blocker on mortality in geriatric patients undergoing emergency laparotomy. Material and Methods: This is a retrospective study of patients who underwent emergency laparotomy between 1 January 2015 and 31 December 2016 at a single institution. The outcomes of interest were the association between post-operative complications and in-hospital and 1-year mortality in patients on beta-blocker therapy (BB(+)) and those who were not (BB(−)). The Poisson regression analysis was used to evaluate the association. Results: A total of 192 patients were included of whom 62 (32.2%) had pre-operative beta-blocker therapy with continued exposure during their hospital stay. The in-hospital mortality was 17.7% in the BB(+) and 23.8% in the BB(−) cohorts ( p = 0.441). One-year mortality was significantly lower in the BB(+) group compared to the BB(−) group (30.6% versus 47.7%; p = 0.038). After adjusting for confounders, the incidence of deaths during 1 year post-operatively decreased by 35% in the BB(+) group (incidence rate ratio = 0.65, p = 0.004). No significant differences in the incidence of post-operative complications between the two groups could be measured. Conclusion: Beta-blocker therapy may be associated with reduced 1-year mortality following emergency laparotomy in geriatric patients.
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Affiliation(s)
- S. Maghami
- Center for Trauma and Critical Care, Department of Surgery, The George Washington University School of Medicine & Health Sciences, Washington, DC, USA
| | - Y. Cao
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Orebro University, Orebro, Sweden
| | - R. Ahl
- Department of Surgery, Karolinska University Hospital, Stockholm, Sweden
- School of Medical Sciences, Orebro University, Orebro, Sweden
| | - E. Detlofsson
- Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital, Orebro, Sweden
| | - P. Matthiessen
- School of Medical Sciences, Orebro University, Orebro, Sweden
- Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital, Orebro, Sweden
| | - B. Sarani
- Center for Trauma and Critical Care, Department of Surgery, The George Washington University School of Medicine & Health Sciences, Washington, DC, USA
| | - S. Mohseni
- School of Medical Sciences, Orebro University, Orebro, Sweden
- Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital, Orebro, Sweden
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Tan K, Harazim M, Tang B, Mclean A, Nalos M. The association between premorbid beta blocker exposure and mortality in sepsis-a systematic review. Crit Care 2019; 23:298. [PMID: 31484576 PMCID: PMC6727531 DOI: 10.1186/s13054-019-2562-y] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 08/07/2019] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND The effect of premorbid β-blocker exposure on clinical outcomes in patients with sepsis is not well characterized. We aimed to examine the association between premorbid β-blocker exposure and mortality in sepsis. METHODS EMBase, MEDLINE, and Cochrane databases were searched for all studies of premorbid β-blocker and sepsis. The search was last updated on 22 June 2019. Two reviewers independently assessed, selected, and abstracted data from studies reporting chronic β-blocker use prior to sepsis and mortality. Main data extracted were premorbid β-blocker exposure, mortality, study design, and patient data. Two reviewers independently assessed the risk of bias and quality of evidence. RESULTS In total, nine studies comprising 56,414 patients with sepsis including 6576 patients with premorbid exposure to β-blockers were eligible. For the primary outcome of mortality, two retrospective studies reported adjusted odds ratios showing a reduction in mortality with premorbid β-blocker exposure. One study showed that premorbid β-blocker exposure decreases mortality in patients with septic shock. Another study showed that continued β-blockade during sepsis is associated with decreased mortality. CONCLUSION This systematic review suggests that β-blocker exposure prior to sepsis is associated with reduced mortality. There was insufficient data to conduct a bona fide meta-analysis. Whether the apparent reduction in mortality may be attributed to the mitigation of catecholamine excess is unclear. TRIAL REGISTRATION PROSPERO, CRD42019130558 registered June 12, 2019.
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Affiliation(s)
- Kaiquan Tan
- Nepean Clinical School, Sydney Medical School, University of Sydney, Penrith, Australia
| | - Martin Harazim
- Medical Intensive Care Unit, Teaching Hospital and Biomedical Centre, Charles University, Alej Svobody 80, 323 00, Pilsen, Czech Republic
| | - Benjamin Tang
- Nepean Clinical School, Sydney Medical School, University of Sydney, Penrith, Australia
- Centre for Immunology and Allergy Research, Westmead Millennium Institute, Westmead, Australia
| | - Anthony Mclean
- Nepean Clinical School, Sydney Medical School, University of Sydney, Penrith, Australia
- Department of Intensive Care Medicine, Nepean Hospital, Penrith, Australia
| | - Marek Nalos
- Nepean Clinical School, Sydney Medical School, University of Sydney, Penrith, Australia.
- Department of Intensive Care Medicine, Nepean Hospital, Penrith, Australia.
- Medical Intensive Care Unit, Teaching Hospital and Biomedical Centre, Charles University, Alej Svobody 80, 323 00, Pilsen, Czech Republic.
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24
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Kobayashi D, Kuriyama N, Yanase F, Takahashi O, Aoki K, Komatsu Y. Angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker use prior to medical intensive care unit admission and in-hospital mortality: propensity score-matched cohort study. J Nephrol 2019; 32:595-603. [PMID: 30937855 DOI: 10.1007/s40620-019-00603-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 03/26/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND The aim of this study was to evaluate whether angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker (ACEI/ARB) use prior to medical intensive care unit (ICU) admission was associated with in-hospital mortality and length of ICU stay. METHODS A propensity score-matched cohort study was conducted at single center from 2004 to 2016. We included all adult patients who were admitted to the ICU due to internal medicine-related conditions. We compared patients who had used ACEIs/ARBs prior to ICU admission to patients who had not. Our primary and secondary outcomes were in-hospital mortality and length of stay among survivors and the deceased. Propensity scores were calculated via logistic regression analyses with forward stepwise selection. An odds ratio (OR) for primary outcome was calculated via logistic regression. Sensitivity analyses were performed using conditional logistic regression models including different sets of covariates to confirm our results. RESULTS 3095 patients were admitted to the ICU. Overall, 693 patients were identified via matching, 231 of whom had used ACEIs/ARBs and 462 of whom had not. None of the baseline characteristics differed significantly between groups. Among them, 131 (18.9%) died. Those who had used ACEIs/ARBs had a lower rate of mortality (p < 0.01). Length of ICU stay did not differ significantly between those with ACEIs/ARBs and those without among survivors (p = 0.43) and the deceased (p = 0.14). The OR for mortality was 0.51 (95% confidence interval 0.32-0.79). The results of the sensitivity analyses confirmed the results (ORs 0.4 6-0.53; all were statistically significant). CONCLUSION Prior ACEI/ARB use may be related to in-hospital mortality among medical ICU patients.
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Affiliation(s)
- Daiki Kobayashi
- Division of General Internal Medicine, Department of Medicine, St. Luke's International Hospital, Tokyo, Japan. .,Fujita Health University, Toyoake, Japan.
| | - Nagato Kuriyama
- Department of Epidemiology for Community Health and Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Fumitaka Yanase
- Department of Intensive Care Unit, Saitama Medical Center Jichi Medical University, Omiya, Japan
| | - Osamu Takahashi
- Division of General Internal Medicine, Department of Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Kazuhiro Aoki
- Department of Anesthesia and Intensive Care Unit, St. Luke's International Hospital, Tokyo, Japan
| | - Yasuhiro Komatsu
- Division of Nephrology, Department of Medicine, St. Luke's International Hospital, Tokyo, Japan
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25
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Sartini C, Lomivorotov V, Pisano A, Riha H, Baiardo Redaelli M, Lopez-Delgado JC, Pieri M, Hajjar L, Fominskiy E, Likhvantsev V, Cabrini L, Bradic N, Avancini D, Wang CY, Lembo R, Novikov M, Paternoster G, Gazivoda G, Alvaro G, Roasio A, Wang C, Severi L, Pasin L, Mura P, Musu M, Silvetti S, Votta CD, Belletti A, Corradi F, Brusasco C, Tamà S, Ruggeri L, Yong CY, Pasero D, Mancino G, Spadaro S, Conte M, Lobreglio R, Di Fraja D, Saporito E, D'Amico A, Sardo S, Ortalda A, Yavorovskiy A, Riefolo C, Monaco F, Bellomo R, Zangrillo A, Landoni G. A Systematic Review and International Web-Based Survey of Randomized Controlled Trials in the Perioperative and Critical Care Setting: Interventions Increasing Mortality. J Cardiothorac Vasc Anesth 2019; 33:2685-2694. [PMID: 31064730 DOI: 10.1053/j.jvca.2019.03.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 03/10/2019] [Accepted: 03/11/2019] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Reducing mortality is a key target in critical care and perioperative medicine. The authors aimed to identify all nonsurgical interventions (drugs, techniques, strategies) shown by randomized trials to increase mortality in these clinical settings. DESIGN A systematic review of the literature followed by a consensus-based voting process. SETTING A web-based international consensus conference. PARTICIPANTS Two hundred fifty-one physicians from 46 countries. INTERVENTIONS The authors performed a systematic literature search and identified all randomized controlled trials (RCTs) showing a significant increase in unadjusted landmark mortality among surgical or critically ill patients. The authors reviewed such studies during a meeting by a core group of experts. Studies selected after such review advanced to web-based voting by clinicians in relation to agreement, clinical practice, and willingness to include each intervention in international guidelines. MEASUREMENTS AND MAIN RESULTS The authors selected 12 RCTs dealing with 12 interventions increasing mortality: diaspirin-crosslinked hemoglobin (92% of agreement among web voters), overfeeding, nitric oxide synthase inhibitor in septic shock, human growth hormone, thyroxin in acute kidney injury, intravenous salbutamol in acute respiratory distress syndrome, plasma-derived protein C concentrate, aprotinin in high-risk cardiac surgery, cysteine prodrug, hypothermia in meningitis, methylprednisolone in traumatic brain injury, and albumin in traumatic brain injury (72% of agreement). Overall, a high consistency (ranging from 80% to 90%) between agreement and clinical practice was observed. CONCLUSION The authors identified 12 clinical interventions showing increased mortality supported by randomized controlled trials with nonconflicting evidence, and wide agreement upon clinicians on a global scale.
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Affiliation(s)
- Chiara Sartini
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Antonio Pisano
- Division of Cardiac Anesthesia and Intensive Care Unit, AORN dei Colli - Monaldi Hospital, Naples, Italy
| | - Hynek Riha
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Martina Baiardo Redaelli
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Marina Pieri
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Ludhmila Hajjar
- Instituto do Coracao do Hospital das Clinicas, Sao Paulo, Brazil
| | - Evgeny Fominskiy
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Valery Likhvantsev
- Department of Anesthesiology and Intensive Care, Sechenov First Moscow State Medical University, and Moscow Regional Clinical and Research Institute, Moscow, Russian Federation
| | - Luca Cabrini
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Nikola Bradic
- Department of Cardiovascular Anesthesiology and Cardiac Intensive Medicine, University Hospital Dubrava, Zagreb, Croatia
| | - Daniele Avancini
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Chew Yin Wang
- Anaesthesia and Intensive Care, University of Malaya, Kuala Lumpur, Malaysia
| | - Rosalba Lembo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Maxim Novikov
- Saint Petersburg State University, Saint Petersburg, Russia
| | | | - Gordana Gazivoda
- Institute of Cardiovascular Diseases "Dedinje", Belgrade, Serbia
| | | | - Agostino Roasio
- Department of Anaesthesia and Intensive Care, Ospedale Cardinal Massaia di Asti, Asti, Italy
| | - Chengbin Wang
- Center for Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Luca Severi
- Anesthesia and Intensive Care, Azienda Ospedaliera San Camillo Forlanini, Rome, Italy
| | | | - Paolo Mura
- Department of Anesthesia and Intensive Care Unit, Policlinico Duilio Casula AOU, Cagliari, Italy
| | - Mario Musu
- Department of Medical Sciences and Public Health, University of Cagliari, Monserrato, Italy
| | - Simona Silvetti
- IRCCS Istituto Giannina Gaslini, Ospedale Pediatrico, Genoa, Italy
| | - Carmine Domenico Votta
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Belletti
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Corradi
- E.O. Ospedali Galliera, Genova, Italy and Università degli Studi di Pisa, Italy
| | - Claudia Brusasco
- E.O. Ospedali Galliera, Genova, Italy and Università degli Studi di Pisa, Italy
| | - Simona Tamà
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Laura Ruggeri
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Chow-Yen Yong
- Anaesthesia and Intensive Care, Hospital Pulau Pinang, Georgetown, Malaysia
| | - Daniela Pasero
- Department of Anesthesia and Intensive Care, A.O.U. Cittàdella Salute e della Scienza, Turin, Italy
| | | | - Savino Spadaro
- Department Morphology, Surgery and Experimental Medicine, Intensive Care Unit, University of Ferrara, Italy
| | | | - Rosetta Lobreglio
- Anesthesia and Intensive Care A.O.U Città della salute e della Scienza, Turin, Italy
| | - Diana Di Fraja
- Division of Cardiac Anesthesia and Intensive Care Unit, AORN dei Colli - Monaldi Hospital, Naples, Italy
| | | | | | - Salvatore Sardo
- Department of Medical Sciences and Public Health, University of Cagliari, Monserrato, Italy
| | - Alessandro Ortalda
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Andrey Yavorovskiy
- Department of Anesthesiology and Intensive Care, Sechenov First Moscow State Medical University, and Moscow Regional Clinical and Research Institute, Moscow, Russian Federation
| | - Claudio Riefolo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Fabrizio Monaco
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre, Melbourne, Australia
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy.
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26
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Lee YR, Seth MS, Soney D, Dai H. Benefits of Beta-Blockade in Sepsis and Septic Shock: A Systematic Review. Clin Drug Investig 2019; 39:429-440. [DOI: 10.1007/s40261-019-00762-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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27
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Eriksson M, von Oelreich E, Brattström O, Eriksson J, Larsson E, Oldner A. Effect of preadmission beta-blockade on mortality in multiple trauma. BJS Open 2018; 2:392-399. [PMID: 30511040 PMCID: PMC6253788 DOI: 10.1002/bjs5.83] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 05/03/2018] [Indexed: 11/08/2022] Open
Abstract
Background High levels of circulating catecholamines after multiple trauma have been associated with increased morbidity and mortality. Beta‐adrenergic receptor antagonist (beta‐blocker) therapy has emerged as a potential treatment option, but the effect of preinjury beta‐blockade on trauma‐induced mortality is unclear. The aim of this study was to assess whether preinjury beta‐blocker therapy is associated with reduced mortality after multiple trauma. Methods Severely injured patients, aged at least 50 years, admitted to a level one trauma centre over a 10‐year interval were linked to national and local registries of co‐morbidities, prescription drug use and level of education. The association between preinjury beta‐blocker use and 30‐day mortality was explored using logistic regression analysis. Results Some 1376 patients were included; 338 (24·6 per cent) were receiving beta‐blockers at the time of trauma. Beta‐blocker users had an increased crude 30‐day mortality rate compared with that for non‐users: 32·8 versus 19·7 per cent respectively (P < 0·001). After adjustment for baseline imbalances and injury‐related factors, there was no association between preinjury beta‐blocker use and mortality (OR 1·09, 95 per cent c.i. 0·70 to 1·70). Separate analyses of individuals with or without severe head injury did not significantly change this association. There was no significant difference in the rate of shock between beta‐blocker users and non‐users. Conclusion Pretrauma beta‐blockade is not associated with 30‐day mortality beyond the effects of age, co‐morbidity and injury severity.
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Affiliation(s)
- M Eriksson
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna Stockholm Sweden.,Section of Anaesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet Stockholm Sweden
| | - E von Oelreich
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna Stockholm Sweden.,Section of Anaesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet Stockholm Sweden
| | - O Brattström
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna Stockholm Sweden.,Section of Anaesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet Stockholm Sweden
| | - J Eriksson
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna Stockholm Sweden.,Section of Anaesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet Stockholm Sweden
| | - E Larsson
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna Stockholm Sweden.,Section of Anaesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet Stockholm Sweden
| | - A Oldner
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna Stockholm Sweden.,Section of Anaesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet Stockholm Sweden
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28
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van Loon LM, van der Hoeven JG, Lemson J. Hemodynamic response to β-blockers in severe sepsis and septic shock: A review of current literature. J Crit Care 2018; 50:138-143. [PMID: 30540967 DOI: 10.1016/j.jcrc.2018.12.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 12/03/2018] [Accepted: 12/04/2018] [Indexed: 12/17/2022]
Abstract
The administration of β-blockers in patients with sepsis is a trending topic in intensive care medicine since the landmark study by Morelli and colleagues, showing a striking decrease in 28-day mortality compared to standard care. While the available evidence suggests that the use of β-blockers in septic shock is safe, the effects on hemodynamics are controversial. In this paper, we review the effect of β-blockade in septic shock on hemodynamics from animal models to critically ill patients.
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Affiliation(s)
- Lex M van Loon
- Biomedical Signals and Systems, Faculty of Electrical Engineering, Mathematics and Computer Science, Technical Medical Centre, University of Twente, Postbox 217, 7500 AE Enschede, the Netherlands; Department of Critical Care Medicine (707), Radboud university medical center, PO Box 9101, 6500 HB Nijmegen, the Netherlands.
| | - Johannes G van der Hoeven
- Department of Critical Care Medicine (707), Radboud university medical center, PO Box 9101, 6500 HB Nijmegen, the Netherlands
| | - Joris Lemson
- Department of Critical Care Medicine (707), Radboud university medical center, PO Box 9101, 6500 HB Nijmegen, the Netherlands
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29
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De Backer D, Pinsky M. Norepinephrine improves cardiac function during septic shock, but why? Br J Anaesth 2018; 120:421-424. [DOI: 10.1016/j.bja.2017.11.069] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Revised: 11/18/2017] [Accepted: 11/18/2017] [Indexed: 10/18/2022] Open
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30
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Fuchs C. Response to ‘Septic shock, Warburg effect, quorum sensing, and adrenergic blockers’. Br J Anaesth 2018; 120:413-414. [DOI: 10.1016/j.bja.2017.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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31
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Natesan V. Adrenergic blockade inhibits bacterial quorum sensing and reverses Warburg effect in septic shock. Br J Anaesth 2018; 120:412-413. [DOI: 10.1016/j.bja.2017.12.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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32
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Rehberg S, Joannidis M, Whitehouse T, Morelli A. Landiolol for managing atrial fibrillation in intensive care. Eur Heart J Suppl 2018; 20:A15-A18. [PMID: 30188960 PMCID: PMC5909768 DOI: 10.1093/eurheartj/sux039] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Landiolol is an injectable ultrashort acting beta-blocker with high beta1 selectivity indicated for heart rate control of atrial fibrillation in the emergency and critical care setting. Accordingly, landiolol is associated with a significantly reduced risk of arterial hypotension and negative inotropic effects. Based on this particular profile along with the clinical experience in Japan for more than a decade landiolol represents a promising agent for the management of elevated heart rate and atrial fibrillation in intensive care patients even with catecholamine requirements. This article provides a review and perspective of landiolol for heart rate control in intensive care patients based on the current literature.
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Affiliation(s)
- Sebastian Rehberg
- Department of Anaesthesiology, University Hospital of Greifswald, Greifswald, Germany
| | - Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Tony Whitehouse
- Department of Critical Care and Anaesthesia, University Hospital Birmingham, Edgbaston, Birmingham, UK
| | - Andrea Morelli
- Department of Anesthesiology and Intensive Care Medicine, University of Rome "La Sapienza", Italy Policlinico Umberto I° Hospital, Viale del Policlinico 155, Rome, Italy
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33
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Leitao Filho FS, Alotaibi NM, Yamasaki K, Ngan DA, Sin DD. The role of beta-blockers in the management of chronic obstructive pulmonary disease. Expert Rev Respir Med 2017; 12:125-135. [DOI: 10.1080/17476348.2018.1419869] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Fernando Sergio Leitao Filho
- Centre for Heart Lung Innovation, St. Paul´s Hospital, & Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Nawaf M. Alotaibi
- Centre for Heart Lung Innovation, St. Paul´s Hospital, & Department of Medicine, University of British Columbia, Vancouver, BC, Canada
- Division of Pulmonary Medicine, Department of Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Kei Yamasaki
- Centre for Heart Lung Innovation, St. Paul´s Hospital, & Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - David A. Ngan
- Centre for Heart Lung Innovation, St. Paul´s Hospital, & Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Don D. Sin
- Centre for Heart Lung Innovation, St. Paul´s Hospital, & Department of Medicine, University of British Columbia, Vancouver, BC, Canada
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34
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Microcirculation First!-Esmolol, a Candidate for the Next Term of Office. Crit Care Med 2017; 45:2115-2116. [PMID: 29148995 DOI: 10.1097/ccm.0000000000002757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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35
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Boerma E, Singer M. Beta-blockers in sepsis: time to reconsider current constraints? Br J Anaesth 2017; 119:560-561. [DOI: 10.1093/bja/aex266] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
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