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D'Amico F, Pruna A, Putowski Z, Dormio S, Ajello S, Scandroglio AM, Lee TC, Zangrillo A, Landoni G. Low Versus High Blood Pressure Targets in Critically Ill and Surgical Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Crit Care Med 2024:00003246-990000000-00330. [PMID: 38656245 DOI: 10.1097/ccm.0000000000006314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
OBJECTIVES Hypotension is associated with adverse outcomes in critically ill and perioperative patients. However, these assumptions are supported by observational studies. This meta-analysis of randomized controlled trials aims to compare the impact of lower versus higher blood pressure targets on mortality. DATA SOURCES We searched PubMed, Cochrane, and Scholar from inception to February 10, 2024. STUDY SELECTION Randomized trials comparing lower versus higher blood pressure targets in the management of critically ill and perioperative settings. DATA EXTRACTION The primary outcome was all-cause mortality at the longest follow-up available. This review was registered in the Prospective International Register of Systematic Reviews, CRD42023452928. DATA SYNTHESIS Of 2940 studies identified by the search string, 28 (12 in critically ill and 16 in perioperative settings) were included totaling 15,672 patients. Patients in the low blood pressure target group had lower mortality (23 studies included: 1019/7679 [13.3%] vs. 1103/7649 [14.4%]; relative risk 0.93; 95% CI, 0.87-0.99; p = 0.03; I2 = 0%). This corresponded to a 97.4% probability of any increase in mortality with a Bayesian approach. These findings were mainly driven by studies performed in the ICU setting and with treatment lasting more than 24 hours; however, the magnitude and direction of the results were similar in the majority of sensitivity analyses including the analysis restricted to low risk of bias studies. We also observed a lower rate of atrial fibrillation and fewer patients requiring transfusion in low-pressure target groups. No differences were found in the other secondary outcomes. CONCLUSIONS Based on pooled randomized trial evidence, a lower compared with a higher blood pressure target results in a reduction of mortality, atrial fibrillation, and transfusion requirements. Lower blood pressure targets may be beneficial but there is ongoing uncertainty. However, the present meta-analysis does not confirm previous findings and recommendations. These results might inform future guidelines and promote the study of the concept of protective hemodynamics.
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Affiliation(s)
- Filippo D'Amico
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Pruna
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Zbigniew Putowski
- Department of Intensive Care and Perioperative Medicine, Center for Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Sara Dormio
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Silvia Ajello
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Anna Mara Scandroglio
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Todd C Lee
- Division of Infectious Diseases, Department of Medicine, McGill University, Montreal, QC, Canada
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
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2
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D'Amico F, Fominskiy EV, Turi S, Pruna A, Fresilli S, Triulzi M, Zangrillo A, Landoni G. Intraoperative hypotension and postoperative outcomes: a meta-analysis of randomised trials. Br J Anaesth 2023; 131:823-831. [PMID: 37739903 DOI: 10.1016/j.bja.2023.08.026] [Citation(s) in RCA: 27] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 08/11/2023] [Accepted: 08/16/2023] [Indexed: 09/24/2023] Open
Abstract
INTRODUCTION Intraoperative hypotension is associated with adverse postoperative outcomes; however these findings are supported only by observational studies. The aim of this meta-analysis of randomised trials was to compare the postoperative effects permissive management with targeted management of intraoperative blood pressure. METHODS We searched PubMed, Cochrane, and Embase up to June 2023 for studies comparing permissive (mean arterial pressure ≤60 mm Hg) with targeted (mean arterial pressure >60 mm Hg) intraoperative blood pressure management. Primary outcome was all-cause mortality at the longest follow-up available. Secondary outcomes were atrial fibrillation, myocardial infarction, acute kidney injury, delirium, stroke, number of patients requiring transfusion, time on mechanical ventilation, and length of hospital stay. RESULTS We included 10 randomised trials including a total of 9359 patients. Mortality was similar between permissive and targeted blood pressure management groups (89/4644 [1.9%] vs 99/4643 [2.1%], odds ratio 0.88, 95% confidence interval [CI], 0.65-1.18, P=0.38, I2=0% with nine studies included). Atrial fibrillation (102/3896 [2.6%] vs 130/3887 [3.3%] odds ratio 0.71, 95% CI 0.53-0.96, P=0.03, I2=0%), and length of hospital stay (mean difference -0.20 days, 95% CI -0.26 to -0.13, P<0.001, I2=0%) were reduced in the permissive management group. No significant differences were found in subgroup analysis for cardiac and noncardiac surgery. CONCLUSION Pooled randomised evidence shows that a target intraoperative mean arterial pressure ≤60 mm Hg is not associated with increased mortality; nevertheless it is surprisingly associated with a reduced rate of atrial fibrillation and of length of hospital stay. SYSTEMATIC REVIEW PROTOCOL PROSPERO CRD42023393725.
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Affiliation(s)
- Filippo D'Amico
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Evgeny V Fominskiy
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Stefano Turi
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Pruna
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Stefano Fresilli
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Margherita Triulzi
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; School of Medicine, Vita-Salute San Raffaele University, Milan, Italy.
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Rasmussen SB, Boyko Y, Ranucci M, de Somer F, Ravn HB. Cardiac surgery-Associated acute kidney injury - A narrative review. Perfusion 2023:2676591231211503. [PMID: 37905794 DOI: 10.1177/02676591231211503] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Abstract
Cardiac Surgery-Associated Acute Kidney Injury (CSA-AKI) is a serious complication seen in approximately 20-30% of cardiac surgery patients. The underlying pathophysiology is complex, often involving both patient- and procedure related risk factors. In contrast to AKI occurring after other types of major surgery, the use of cardiopulmonary bypass comprises both additional advantages and challenges, including non-pulsatile flow, targeted blood flow and pressure as well as the ability to manipulate central venous pressure (congestion). With an increasing focus on the impact of CSA-AKI on both short and long-term mortality, early identification and management of high-risk patients for CSA-AKI has evolved. The present narrative review gives an up-to-date summary on definition, diagnosis, underlying pathophysiology, monitoring and implications of CSA-AKI, including potential preventive interventions. The review will provide the reader with an in-depth understanding of how to identify, support and provide a more personalized and tailored perioperative management to avoid development of CSA-AKI.
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Affiliation(s)
- Sebastian Buhl Rasmussen
- Department of Anaesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Yuliya Boyko
- Department of Anaesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
| | - Marco Ranucci
- Department of Cardiovascular Anaesthesiology and Intensive Care, IRCCS Policlinico San Donato, Milan, Italy
| | | | - Hanne Berg Ravn
- Department of Anaesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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Norepinephrine and Vasopressin in Hemorrhagic Shock: A Focus on Renal Hemodynamics. Int J Mol Sci 2023; 24:ijms24044103. [PMID: 36835514 PMCID: PMC9967703 DOI: 10.3390/ijms24044103] [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: 01/02/2023] [Revised: 02/01/2023] [Accepted: 02/15/2023] [Indexed: 02/22/2023] Open
Abstract
During hemorrhagic shock, blood loss causes a fall in blood pressure, decreases cardiac output, and, consequently, O2 transport. The current guidelines recommend the administration of vasopressors in addition to fluids to maintain arterial pressure when life-threatening hypotension occurs in order to prevent the risk of organ failure, especially acute kidney injury. However, different vasopressors exert variable effects on the kidney, depending on the nature and dose of the substance chosen as follows: Norepinephrine increases mean arterial pressure both via its α-1-mediated vasoconstriction leading to increased systemic vascular resistance and its β1-related increase in cardiac output. Vasopressin, through activation of V1-a receptors, induces vasoconstriction, thus increasing mean arterial pressure. In addition, these vasopressors have the following different effects on renal hemodynamics: Norepinephrine constricts both the afferent and efferent arterioles, whereas vasopressin exerts its vasoconstrictor properties mainly on the efferent arteriole. Therefore, this narrative review discusses the current knowledge of the renal hemodynamic effects of norepinephrine and vasopressin during hemorrhagic shock.
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Yavuz Ş, Engin M, Aydın U, Ata Y. Which inotropic agents should be used in cardiac surgery? What dose should be used? J Card Surg 2022; 37:2489-2490. [PMID: 35419872 DOI: 10.1111/jocs.16518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 04/05/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Şenol Yavuz
- Department of Cardiovascular Surgery, Bursa Yuksek Ihtisas Training and Research Hospital, University of Health Sciences, Bursa, Turkey
| | - Mesut Engin
- Department of Cardiovascular Surgery, Bursa Yuksek Ihtisas Training and Research Hospital, University of Health Sciences, Bursa, Turkey
| | - Ufuk Aydın
- Department of Cardiovascular Surgery, Bursa Yuksek Ihtisas Training and Research Hospital, University of Health Sciences, Bursa, Turkey
| | - Yusuf Ata
- Department of Cardiovascular Surgery, Bursa Yuksek Ihtisas Training and Research Hospital, University of Health Sciences, Bursa, Turkey
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6
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Libert N, Laemmel E, Harrois A, Laitselart P, Bergis B, Isnard P, Terzi F, Decante B, Mercier O, Vicaut E, Duranteau J. Renal Microcirculation and Function in a Pig Model of Hemorrhagic Shock Resuscitation with Norepinephrine. Am J Respir Crit Care Med 2022; 206:34-43. [PMID: 35394403 DOI: 10.1164/rccm.202109-2120oc] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Norepinephrine (NE) is commonly used in combination with fluid during resuscitation of hemorrhagic shock, however its impact on kidney microcirculation, oxygenation and function is still unknown in this setting. OBJECTIVES During hemorrhagic shock resuscitation, does a combination of fluid and norepinephrine affect kidney oxygenation tension, kidney microcirculatory perfusion and 48-hour kidney function, as compared to fluid alone? METHODS Hemorrhagic shock was induced in 24 pigs and 8 pigs were included as sham. Resuscitation of hemorrhagic shock was performed, using a closed-loop device, either by fluid alone (0.9% NaCl, Fluid group) or associated with the administration of NE at two doses (moderate dose: mean rate of 0.64 µg.kg-1.min-1 and high dose: mean rate of 1.57 µg.kg-1.min-1) in order to obtain SAP (systolic arterial pressure) target of 80-90 mmHg. Resuscitation was followed by transfusion of the withdrawn blood. MEASUREMENTS AND MAIN RESULTS The amount of fluid required to reach SAP target was lower in NE groups than in Fluid group with subsequent less hemodilution. Norepinephrine restored kidney microcirculation, oxygenation, and function in a manner comparable to that achieved with fluid resuscitation alone. There were no histological differences among animals resuscitated with Fluid or with NE. CONCLUSION In pigs with hemorrhagic shock, resuscitation with a combination of NE and fluid restored kidney microcirculation and oxygenation, as well as renal function, in a manner comparable to fluid resuscitation alone and without differences between the two NE doses. NE administration led to a fluid volume sparing effect with subsequently less hemodilution.
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Affiliation(s)
- Nicolas Libert
- Hôpital d'instruction des armées Percy, Département d'anesthésie réanimation, Clamart, France.,Université Paris 7 Denis Diderot, 555089, Laboratoire d'Étude de la Microcirculation, UMR 942, Paris, France
| | - Elisabeth Laemmel
- Université Paris 7 Denis Diderot, 555089, Laboratoire d'Étude de la Microcirculation, UMR 942, Paris, France
| | - Anatole Harrois
- Hopital Bicetre, 41664, Anesthesiology and surgical intensive care, Le Kremlin-Bicetre, France.,Université Paris 7 Denis Diderot, 555089, Laboratoire d'Étude de la Microcirculation, UMR 942, Paris, France
| | - Philippe Laitselart
- Hôpital d'instruction des armées Percy, Département d'anesthésie réanimation, Clamart, France.,Université Paris 7 Denis Diderot, 555089, Laboratoire d'Étude de la Microcirculation, UMR 942, Paris, France
| | - Benjamin Bergis
- Hopital Bicetre, 41664, Anesthesiology and surgical intensive care, Le Kremlin-Bicetre, France.,Université Paris 7 Denis Diderot, 555089, Laboratoire d'Étude de la Microcirculation, UMR 942, Paris, France
| | - Pierre Isnard
- Hopital Necker-Enfants Malades, 246596, Anatomy and Cytology Pathology, Paris, France
| | - Fabiola Terzi
- INSERM U1151, 554251, CNRS UMR 8253, Institut Necker Enfants Malades, Département , Paris, France
| | - Benoit Decante
- Hôpital Marie Lannelongue , Unité de recherche et d'innovation, Le Plessis Robinson, France
| | - Olaf Mercier
- Université Paris-Sud Faculté de Médecine, 89691, École de médecine, Le Kremlin-Bicetre, France.,INSERM UMR_S999, 130034, Département de chirurgie thoracique et vasculaire et transplantation cœur-poumon, DHU Thorax Innovation, LabEx LERMIT, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Eric Vicaut
- Assistance Publique - Hopitaux de Paris, 26930, Paris, France.,Université Paris 7 Denis Diderot, 555089, Laboratoire d'Étude de la Microcirculation, UMR 942, Paris, France
| | - Jacques Duranteau
- Bicêtre University Hospital, Anesthesia and Intensive Care Department, Le Kremlin-Bicêtre, France.,Université Paris 7 Denis Diderot, 555089, Laboratoire d'Étude de la Microcirculation, UMR 942, Paris, France;
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7
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Kim M, Li G, Mohan S, Turnbull ZA, Kiran RP, Li G. Intraoperative Data Enhance the Detection of High-Risk Acute Kidney Injury Patients When Added to a Baseline Prediction Model. Anesth Analg 2021; 132:430-441. [PMID: 32769380 DOI: 10.1213/ane.0000000000005057] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Aspects of intraoperative management (eg, hypotension) are associated with acute kidney injury (AKI) in noncardiac surgery patients. However, it is unclear if and how the addition of intraoperative data affects a baseline risk prediction model for postoperative AKI. METHODS With institutional review board (IRB) approval, an institutional cohort (2005-2015) of inpatient intra-abdominal surgery patients without preoperative AKI was identified. Data from the American College of Surgeons National Surgical Quality Improvement Program (preoperative and procedure data), Anesthesia Information Management System (intraoperative data), and electronic health record (postoperative laboratory data) were linked. The sample was split into derivation/validation (70%/30%) cohorts. AKI was defined as an increase in serum creatinine ≥0.3 mg/dL within 48 hours or >50% within 7 days of surgery. Forward logistic regression fit a baseline model incorporating preoperative variables and surgical procedure. Forward logistic regression fit a second model incorporating the previously selected baseline variables, as well as additional intraoperative variables. Intraoperative variables reflected the following aspects of intraoperative management: anesthetics, beta-blockers, blood pressure, diuretics, fluids, operative time, opioids, and vasopressors. The baseline and intraoperative models were evaluated based on statistical significance and discriminative ability (c-statistic). The risk threshold equalizing sensitivity and specificity in the intraoperative model was identified. RESULTS Of 2691 patients in the derivation cohort, 234 (8.7%) developed AKI. The baseline model had c-statistic 0.77 (95% confidence interval [CI], 0.74-0.80). The additional variables added to the intraoperative model were significantly associated with AKI (P < .0001) and the intraoperative model had c-statistic 0.81 (95% CI, 0.78-0.83). Sensitivity and specificity were equalized at a risk threshold of 9.0% in the intraoperative model. At this threshold, the baseline model had sensitivity and specificity of 71% (95% CI, 65-76) and 69% (95% CI, 67-70), respectively, and the intraoperative model had sensitivity and specificity of 74% (95% CI, 69-80) and 74% (95% CI, 73-76), respectively. The high-risk group had an AKI risk of 18% (95% CI, 15-20) in the baseline model and 22% (95% CI, 19-25) in the intraoperative model. CONCLUSIONS Intraoperative data, when added to a baseline risk prediction model for postoperative AKI in intra-abdominal surgery patients, improves the performance of the model.
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Affiliation(s)
- Minjae Kim
- From the Department of Anesthesiology, Columbia University Medical Center, New York, New York.,Department of Epidemiology
| | - Gen Li
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, New York
| | - Sumit Mohan
- Department of Epidemiology.,Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Zachary A Turnbull
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York
| | - Ravi P Kiran
- Department of Epidemiology.,Division of Colorectal Surgery, Department of Surgery, Columbia University Medical Center, New York, New York
| | - Guohua Li
- From the Department of Anesthesiology, Columbia University Medical Center, New York, New York.,Department of Epidemiology
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8
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Lee K, Jeon J, Kim JM, Kim G, Kim K, Jang HR, Lee JE, Joh JW, Lee SK, Huh W. Perioperative risk factors of progressive chronic kidney disease following liver transplantation: analyses of a 10-year follow-up single-center cohort. Ann Surg Treat Res 2020; 99:52-62. [PMID: 32676482 PMCID: PMC7332318 DOI: 10.4174/astr.2020.99.1.52] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 03/28/2020] [Accepted: 04/28/2020] [Indexed: 02/08/2023] Open
Abstract
Purpose The incidence of chronic kidney disease (CKD) has been increasing due to improved survival after liver transplantation (LT). Risk factors of kidney injury after LT, especially perioperative management factors, are potentially modifiable. We investigated the risk factors associated with progressive CKD for 10 years after LT. Methods This retrospective cohort study included 292 adult patients who underwent LT at a tertiary referral hospital between 2000 and 2008. Renal function was assessed by the e stimated glomerular filtration rate (eGFR) using the Modification of Diet in Renal Disease formula. The area under the curve of serial eGFR (AUCeGFR) was calculated for each patient to assess the trajectory of eGFR over the 10 years. Low AUCeGFR was considered progressive CKD. Linear regression analyses were performed to examine the associations between the variables and AUCeGFR. Results Multivariable analysis showed that older age (regression coefficient = -0.53, P < 0.001), diabetes mellitus (DM) (regression coefficient = -6.93, P = 0.007), preoperative proteinuria (regression coefficient = -16.11, P < 0.001), preoperative acute kidney injury (AKI) (regression coefficient = -14.35, P < 0.001), postoperative AKI (regression coefficient = -3.86, P = 0.007), and postoperative mean vasopressor score (regression coefficient = -0.45, P = 0.034) were independently associated with progressive CKD. Conclusion More careful renoprotective management is required in elderly LT patients with DM or preexisting proteinuria. Postoperative AKI and vasopressor dose may be potentially modifiable risk factors for progressive CKD.
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Affiliation(s)
- Kyungho Lee
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Junseok Jeon
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong Man Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Gaabsoo Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyunga Kim
- Statistics and Data Center, Research Institute for Future Medicine, Samsung Medical Center, Seoul, Korea
| | - Hye Ryoun Jang
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung Eun Lee
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae-Won Joh
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Suk-Koo Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Wooseong Huh
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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9
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Eriksen JK, Nielsen LH, Moeslund N, Keller AK, Krag S, Pedersen M, Pedersen JAK, Birn H, Jespersen B, Norregaard R. Goal-Directed Fluid Therapy Does Not Improve Early Glomerular Filtration Rate in a Porcine Renal Transplantation Model. Anesth Analg 2019; 130:599-609. [PMID: 31609257 PMCID: PMC7012341 DOI: 10.1213/ane.0000000000004453] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND: Insufficient fluid administration intra- and postoperatively may lead to delayed renal graft function (DGF), while fluid overload increases the risk of heart failure, infection, and obstipation. Several different fluid protocols have been suggested to ensure optimal fluid state. However, there is a lack of evidence of the clinical impact of these regimens. This study aimed to determine whether individualized goal-directed fluid therapy (IGDT) positively affects the initial renal function compared to a high-volume fluid therapy (HVFT) and to examine the effects on renal endothelial glycocalyx, inflammatory and oxidative stress markers, and medullary tissue oxygenation. The hypothesis was that IGDT improves early glomerular filtration rate (GFR) in pigs subjected to renal transplantation. METHODS: This was an experimental randomized study. Using a porcine renal transplantation model, animals were randomly assigned to receive IGDT or HVFT during and until 1 hour after transplantation from brain-dead donors. The kidneys were exposed to 18 hours of cold ischemia. The recipients were observed until 10 hours after reperfusion, which included GFR measured as clearance of chrom-51-ethylendiamintetraacetat (51Cr-EDTA), animal weight, and renal tissue oxygenation by fiber optic probes. The renal expression of inflammatory and oxidative stress markers as well as glomerular endothelial glycocalyx were analyzed in the graft using polymerase chain reaction (PCR) technique and immunofluorescence. RESULTS: Twenty-eight recipient pigs were included for analysis. We found no evidence that IGDT improved early GFR compared to HVFT (P = .45), while animal weight increased more in the HVFT group (a mean difference of 3.4 kg [1.96–4.90]; P < .0001). A better, however nonsignificant, preservation of glomerular glycocalyx (P = .098) and significantly lower levels of the inflammatory marker cyclooxygenase 2 (COX-2) was observed in the IGDT group when compared to HVFT. COX-2 was 1.94 (1.50–2.39; P = .012) times greater in the HVFT group when compared to the IGDT group. No differences were observed in outer medullary tissue oxygenation or oxidative stress markers. CONCLUSIONS: IGDT did not improve early GFR; however, it may reduce tissue inflammation and could possibly lead to preservation of the glycocalyx compared to HVFT.
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Affiliation(s)
- Jonathan Kunisch Eriksen
- From the Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Acute Medicine, Hospital Unit West (HEV), Herning, Denmark
| | - Lise H Nielsen
- From the Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Niels Moeslund
- From the Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | | | - Søren Krag
- Pathology, Aarhus University Hospital, Aarhus, Denmark
| | - Michael Pedersen
- Comparative Medicine Lab, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | - Henrik Birn
- From the Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Bente Jespersen
- From the Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Rikke Norregaard
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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10
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Farag E, Makarova N, Argalious M, Cywinski JB, Benzel E, Kalfas I, Sessler DI. Vasopressor Infusion During Prone Spine Surgery and Acute Renal Injury: A Retrospective Cohort Analysis. Anesth Analg 2019; 129:896-904. [PMID: 31425235 DOI: 10.1213/ane.0000000000003982] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Hypotension is associated with acute kidney injury, but vasopressors used to treat hypotension may also compromise renal function. We therefore tested the hypothesis that vasopressor infusion during complex spine surgery is not associated with impaired renal function. METHODS In this retrospective cohort analysis, we considered adults who had complex spine surgery between January 2005 and September 2014 at the Cleveland Clinic Main Campus. Our primary outcome was postoperative estimated glomerular filtration rate. Secondarily, we evaluated renal function using Acute Kidney Injury Network criteria. We obtained data for 1814 surgeries, including 689 patients (38%) who were given intraoperative vasopressors infusion for ≥30 minutes and 1125 patients (62%) who were not. Five hundred forty patients with and 540 patients without vasopressor infusions were well matched across 32 potential confounding variables. RESULTS In matched patients, vasopressor infusions lasted an average of 173 ± 100 minutes (SD) and were given a median dose (1st quintile, 3rd quintile) of 3.4-mg (1.5, 6.7 mg) phenylephrine equivalents. Mean arterial pressure and the amounts of hypotension were similar in each matched group. The postoperative difference in mean estimated glomerular filtration rate in patients with and without vasopressor infusions was only 0.8 mL/min/1.73 m (95% CI, -0.6 to 2.2 mL/min/1.73 m) (P = .28). Intraoperative vasopressor infusion was also not associated with increased odds of augmented acute kidney injury stage. CONCLUSIONS Clinicians should not avoid typical perioperative doses of vasopressors for fear of promoting kidney injury. Tolerating hypotension to avoid vasopressor use would probably be a poor strategy.
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Affiliation(s)
- Ehab Farag
- From the Departments of General Anesthesiology
- Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Natalya Makarova
- Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Jacek B Cywinski
- From the Departments of General Anesthesiology
- Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Edward Benzel
- Department of Neurosurgery, Center for Spine Health, Neurosurgical Institute, Cleveland Clinic, Cleveland, Ohio
| | - Iain Kalfas
- Department of Neurosurgery, Center for Spine Health, Neurosurgical Institute, Cleveland Clinic, Cleveland, Ohio
| | - Daniel I Sessler
- Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
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11
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Ghanem MA, Shabana AM. Effects of Milrinone continuous intravenous infusion on global cerebral oxygenation and cerebral vasospasm after cerebral aneurysm surgical clipping. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2013.07.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Affiliation(s)
- Mohamed A. Ghanem
- Anesthesia Department, Faculty of Medicine, Mansoura University, Egypt
| | - Amir M. Shabana
- Anesthesia Department, Faculty of Medicine, Mansoura University, Egypt
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12
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Udy A, Roberts JA, Boots RJ, Lipman J. You Only Find what you Look for: The Importance of High Creatinine Clearance in the Critically Ill. Anaesth Intensive Care 2019; 37:11-3. [DOI: 10.1177/0310057x0903700123] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- A. Udy
- University of Queensland Burns Trauma Critical Care Research Centre Department of Intensive Care Medicine Royal Brisbane and Women's Hospital Herston, Queensland
| | - J. A. Roberts
- University of Queensland Burns Trauma Critical Care Research Centre Department of Intensive Care Medicine Royal Brisbane and Women's Hospital Herston, Queensland
| | - R. J. Boots
- University of Queensland Burns Trauma Critical Care Research Centre Department of Intensive Care Medicine Royal Brisbane and Women's Hospital Herston, Queensland
| | - J. Lipman
- University of Queensland Burns Trauma Critical Care Research Centre Department of Intensive Care Medicine Royal Brisbane and Women's Hospital Herston, Queensland
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13
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Skytte Larsson J, Bragadottir G, Redfors B, Ricksten SE. Renal effects of norepinephrine-induced variations in mean arterial pressure after liver transplantation: A randomized cross-over trial. Acta Anaesthesiol Scand 2018; 62:1229-1236. [PMID: 29896798 DOI: 10.1111/aas.13156] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 04/19/2018] [Accepted: 04/20/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND Acute kidney injury is commonly seen after liver transplantation. The optimal perioperative target mean arterial pressure (MAP) for renal filtration, perfusion and oxygenation in liver recipients is not known. The effects of norepinephrine-induced changes in MAP on renal blood flow (RBF), oxygen delivery (RDO2 ), glomerular filtration rate (GFR) and renal oxygenation (=renal oxygen extraction, RO2 Ex) were therefore studied early after liver transplantation. METHODS Ten patients with an intra- and post-operative vasopressor-dependent systemic vasodilation were studied early after liver transplantation during sedation and mechanical ventilation. To achieve target MAP levels of 60, 75 and 90 mm Hg, the norepinephrine infusion rate was randomly and sequentially titrated. At each target MAP, data on cardiac index (CI), RBF and GFR were obtained by transpulmonary thermodilution (PiCCO), the renal vein thermodilution technique and renal extraction of chromium ethylenediaminetetraaceticacid (51 Cr-EDTA), respectively. Renal oxygen consumption (RVO2 ) and extraction (RO2 Ex) were calculated according to standard formulas. RESULTS At a target MAP of 75 mm Hg, CI (13%), RBF (18%), RDO2 (24%), GFR (31%) and RVO2 (20%) were higher while RO2 Ex was unchanged compared to a target MAP of 60 mm Hg. Increasing MAP from 75 up to 90 mm Hg increased RVR by 38% but had no further effects on CI, RBF, RDO2 or GFR. CONCLUSIONS In patients undergoing liver transplantation, RBF and GFR are pressure-dependent at MAP levels below 75 mm Hg. Our results suggest that MAP should probably be targeted to approximately 75 mm Hg for optimal perioperative renal filtration, perfusion and oxygenation in patients undergoing liver transplantation.
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Affiliation(s)
- J. Skytte Larsson
- Department of Anaesthesiology and Intensive Care Medicine; Institution of Clinical Sciences; Sahlgrenska Academy; University of Gothenburg; Sahlgrenska University Hospital; Gothenburg Sweden
| | - G. Bragadottir
- Department of Anaesthesiology and Intensive Care Medicine; Institution of Clinical Sciences; Sahlgrenska Academy; University of Gothenburg; Sahlgrenska University Hospital; Gothenburg Sweden
| | - B. Redfors
- Department of Anaesthesiology and Intensive Care Medicine; Institution of Clinical Sciences; Sahlgrenska Academy; University of Gothenburg; Sahlgrenska University Hospital; Gothenburg Sweden
| | - S.-E. Ricksten
- Department of Anaesthesiology and Intensive Care Medicine; Institution of Clinical Sciences; Sahlgrenska Academy; University of Gothenburg; Sahlgrenska University Hospital; Gothenburg Sweden
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14
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Norepinephrine Administration Is Associated with Higher Mortality in Dialysis Requiring Acute Kidney Injury Patients with Septic Shock. J Clin Med 2018; 7:jcm7090274. [PMID: 30213107 PMCID: PMC6162856 DOI: 10.3390/jcm7090274] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 09/07/2018] [Accepted: 09/09/2018] [Indexed: 12/29/2022] Open
Abstract
(1) Background: Norepinephrine (NE) is the first-line vasoactive agent used in septic shock patients; however, the effect of norepinephrine on dialysis-required septic acute kidney injury (AKI-D) patients is uncertain. (2) Methods: To evaluate the impact of NE on 90-day mortality and renal recovery in septic AKI-D patients, we enrolled patients in intensive care units from 30 hospitals in Taiwan. (3) Results: 372 patients were enrolled and were divided into norepinephrine users and non-users. After adjustment by Inverse probability of treatment weighted (IPTW), there was no significant difference of baseline comorbidities between the two groups. NE users had significantly higher 90-day mortality rate and using NE is a strong predictor of 90-day mortality in the multivariate Cox regression (HR = 1.497, p = 0.027) after adjustment. The generalized additive model disclosed norepinephrine alone exerted a dose–dependent effect on 90-day mortality, while other vasoactive agents were not. (4) Conclusion: Using norepinephrine in septic AKI-D patients is associated with higher 90-day mortality and the effect is dose-dependent. Further study to explore the potential mechanism is needed.
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Zhi DY, Lin J, Zhuang HZ, Dong L, Ji XJ, Guo DC, Yang XW, Liu S, Yue Z, Yu SJ, Duan ML. Acute Kidney Injury in Critically Ill Patients with Sepsis: Clinical Characteristics and Outcomes. J INVEST SURG 2018; 32:689-696. [PMID: 29693474 DOI: 10.1080/08941939.2018.1453891] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Objective: The objectives of this study were to examine the clinical profile of critically ill patients with septic acute kidney injury (AKI) and to investigate clinical characteristics associated with the outcome of patients. Methods: Data from 582 critically ill patients were collected and retrospectively reviewed. Patients were divided into two groups: without AKI development and with AKI development. Baseline characteristics, laboratory, and other clinical data were compared between these two groups, and correlations between the characteristics and AKI development were examined. Patients with AKI development were further divided into two groups according to the survival outcome, and variables associated with the outcome were determined. Results: AKI was developed in 54.12% (n = 315) of patients, and these patients had blood pressure, SOFA score, APACHE II score, GCS, and various blood chemistry and hematology characteristics significantly different from the patients without AKI. Demographic characteristics (e.g. age and weight) were comparable between the two groups of patients. Among the 315 patients with AKI, 136 of them died during the study period. Multivariate logistic regression analysis revealed that the outcome of patients was associated with lung infection, coagulation system dysfunction, staphylococcus aureus infection, and use of various treatments (epinephrine, norepinephrine, and the use of mechanical ventilation) after AKI development. Conclusion: AKI occurred in approximately half of the critically ill patients admitted to ICU. The site and type of infections, as well as the use of vasopressor agents, were associated with the outcome.
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Affiliation(s)
- De-Yuan Zhi
- Intensive Care Unit, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Jin Lin
- Intensive Care Unit, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Hai-Zhou Zhuang
- Intensive Care Unit, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Lei Dong
- Intensive Care Unit, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Xiao-Jun Ji
- Intensive Care Unit, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Dong-Cheng Guo
- Intensive Care Unit, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Xiao-Wei Yang
- Intensive Care Unit, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Shuai Liu
- Intensive Care Unit, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Zu Yue
- Intensive Care Unit, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Shu-Jing Yu
- Intensive Care Unit, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Mei-Li Duan
- Intensive Care Unit, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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16
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Abstract
BACKGROUND Sepsis accounts for 10% of intensive care unit admissions and significant healthcare costs. Although the mortality rate from sepsis has been decreasing with better critical care, early identification of septic patients, and prompt interventions, the mortality rate remains 20%-30%. METHOD Review of the English-language literature. RESULTS Norepinephrine is the first-line vasopressor in shock and is associated with a lower mortality rate as well as fewer adverse effects. Dopamine has similar actions but is associated with significantly more tachydysrhythmias and should be reserved for patients with bradycardia. Epinephrine and vasopressin are appropriate second-line vasopressors and may enable use of lower doses of norepinephrine while improving hemodynamics. Inotropes may be added in patients with cardiac dysfunction. CONCLUSION Appropriate treatment of sepsis includes prompt identification, early antimicrobial drug therapy, appropriate fluid resuscitation, and initiation of vasopressors in the presence of continued septic shock. Further research needs to be done to better understand the ideal timing of the addition of a second agent and the optimal combinations of vasopressors for individual patients.
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Affiliation(s)
- Kristin P Colling
- Department of Surgery, Division of Critical Care and Acute Care Surgery, University of Minnesota , Minneapolis Minnesota
| | - Kaysie L Banton
- Department of Surgery, Division of Critical Care and Acute Care Surgery, University of Minnesota , Minneapolis Minnesota
| | - Greg J Beilman
- Department of Surgery, Division of Critical Care and Acute Care Surgery, University of Minnesota , Minneapolis Minnesota
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17
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Garvey AA, Kooi EMW, Dempsey EM. Inotropes for Preterm Infants: 50 Years on Are We Any Wiser? Front Pediatr 2018; 6:88. [PMID: 29682496 PMCID: PMC5898425 DOI: 10.3389/fped.2018.00088] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 03/20/2018] [Indexed: 12/20/2022] Open
Abstract
For almost half a century, inotropes have been administered to preterm infants with the ultimate goal of increasing their blood pressure. A number of trials, the majority of which focused on dopamine administration, have demonstrated increased blood pressure following inotrope administration in preterm infants and have led to continued use of inotropes in our neonatal units. We have also seen an increase in the number of potential agents available to the clinician. However, we now know that hypotension is a much broader concept than blood pressure alone, and our aim should instead be focused on improving end organ perfusion, specifically cerebral perfusion. Only a limited number of studies have incorporated the organ-relevant hemodynamic changes and long-term outcomes when assessing inotropic effects in neonates, the majority of which are observational studies or have a small sample size. In addition, important considerations, including the developing/maturing adrenergic receptors, polymorphisms of these receptors, and other differences in the pharmacokinetics and pharmacodynamics of preterm infants, are only recently being recognized. Certainly, there remains huge variation in practice. The lack of well-conducted randomized controlled trials addressing these relevant outcomes, along with the difficulty executing such RCTs, leaves us with more questions than answers. This review provides an overview of the various inotropic agents currently being used in the care of preterm infants, with a particular focus on their organ/cerebral hemodynamic effects both during and after transition.
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Affiliation(s)
- Aisling A Garvey
- Department of Paediatrics and Child Health, Neonatal Intensive Care Unit, University College Cork, Cork, Ireland.,INFANT, Irish Centre for Fetal and Neonatal Translational Research, University College Cork, Cork, Ireland
| | - Elisabeth M W Kooi
- Department of Paediatrics and Child Health, Neonatal Intensive Care Unit, University College Cork, Cork, Ireland.,Division of Neonatology, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Eugene M Dempsey
- Department of Paediatrics and Child Health, Neonatal Intensive Care Unit, University College Cork, Cork, Ireland.,INFANT, Irish Centre for Fetal and Neonatal Translational Research, University College Cork, Cork, Ireland
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18
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Fayed NA, Yassen KA, Abdulla AR. Comparison Between 2 Strategies of Fluid Management on Blood Loss and Transfusion Requirements During Liver Transplantation. J Cardiothorac Vasc Anesth 2017; 31:1741-1750. [DOI: 10.1053/j.jvca.2017.02.177] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Indexed: 12/16/2022]
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19
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Skytte Larsson J, Bragadottir G, Redfors B, Ricksten SE. Renal function and oxygenation are impaired early after liver transplantation despite hyperdynamic systemic circulation. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:87. [PMID: 28395663 PMCID: PMC5387193 DOI: 10.1186/s13054-017-1675-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Accepted: 03/17/2017] [Indexed: 12/22/2022]
Abstract
Background Acute kidney injury (AKI) occurs frequently after liver transplantation and is associated with the development of chronic kidney disease and increased mortality. There is a lack of data on renal blood flow (RBF), oxygen consumption, glomerular filtration rate (GFR) and renal oxygenation, i.e. the renal oxygen supply/demand relationship, early after liver transplantation. Increased insight into the renal pathophysiology after liver transplantation is needed to improve the prevention and treatment of postoperative AKI. We have therefore studied renal hemodynamics, function and oxygenation early after liver transplantation in humans. Methods Systemic hemodynamic and renal variables were measured during two 30-min periods in liver transplant recipients (n = 12) and post-cardiac surgery patients (controls, n = 73). RBF and GFR were measured by the renal vein retrograde thermodilution technique and by renal extraction of Cr-EDTA (= filtration fraction), respectively. Renal oxygenation was estimated from the renal oxygen extraction. Results In the liver transplant group, GFR decreased by 40% (p < 0.05), compared to the preoperative value. Cardiac index and systemic vascular resistance index were 65% higher (p < 0.001) and 36% lower (p < 0.001), respectively, in the liver transplant recipients compared to the control group. GFR was 27% (p < 0.05) and filtration fraction 40% (p < 0.01) lower in the liver transplant group. Renal vascular resistance was 15% lower (p < 0.05) and RBF was 18% higher (p < 0.05) in liver transplant recipients, but the ratio between RBF and cardiac index was 27% lower (p < 0.001) among the liver-transplanted patients compared to the control group. Renal oxygen consumption and extraction were both higher in the liver transplants, 44% (p < 0.01) and 24% (p < 0.05) respectively. Conclusions Despite the hyperdynamic systemic circulation and renal vasodilation, there is a severe decline in renal function directly after liver transplantation. This decline is accompanied by an impaired renal oxygenation, as the pronounced elevation of renal oxygen consumption is not met by a proportional increase in renal oxygen delivery. This information may provide new insights into renal pathophysiology as a basis for future strategies to prevent/treat AKI after liver transplantation. Trial registration ClinicalTrials.gov, NCT02455115. Registered on 23 April 2015.
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Affiliation(s)
- Jenny Skytte Larsson
- Department of Anesthesiology and Intensive Care Medicine, Institution of Clinical Science, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Blå Stråket 5, plan 5, 413 45, Gothenburg, Sweden.
| | - Gudrun Bragadottir
- Department of Anesthesiology and Intensive Care Medicine, Institution of Clinical Science, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Blå Stråket 5, plan 5, 413 45, Gothenburg, Sweden
| | - Bengt Redfors
- Department of Anesthesiology and Intensive Care Medicine, Institution of Clinical Science, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Blå Stråket 5, plan 5, 413 45, Gothenburg, Sweden
| | - Sven-Erik Ricksten
- Department of Anesthesiology and Intensive Care Medicine, Institution of Clinical Science, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Blå Stråket 5, plan 5, 413 45, Gothenburg, Sweden
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20
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Abstract
Vasopressors and inotropes are used in septic shock in patients who remain hypotensive despite adequate fluid resuscitation. The goal is to increase blood pressure to optimize perfusion to organs. Generally, goal-directed therapy to supra-normal oxygen transport variables cannot be recommended due to lack of benefit. Traditionally, vasopressors and inotropes in septic shock have been started in a step-wise fashion starting with dopamine. Recent data suggest that there may be true differences among vasopressors and inotropes on local tissue perfusion as measured by regional hemodynamic and oxygen transport. When started early in septic shock, norepinephrine decreases mortality, optimizes hemodynamic variables, and improves systemic and regional (eg, renal, gastric mucosal, splanchnic) perfusion. Epinephrine causes a greater increase in cardiac index (CI) and oxygen delivery (DO2 ) and increases gastric mucosal flow, but increases lactic acid and may not adequately preserve splanchnic circulation owing to its predominant vasoconstrictive alpha (α ) effects. Epinephrine may be particularly useful when used earlier in the course of septic shock in young patients and those who do not have any known cardiac abnormalities. Unlike epinephrine, dopamine does not preferentially increase the proportion of CI that preferentially goes to the splanchnic circulation. Dopamine is further limited because it cannot increase CI by more than 35% and is accompanied by tachycardia or tachydysrhythmias. Dopamine, as opposed to norepinephrine, may worsen splanchnic oxygen consumption (VO2 ) and oxygen extraction ratio (O2 ER). Low-dose dopamine has not been shown to consistently increase the glomerular filtration rate or prevent renal failure, and, indeed, worsens splanchnic tissue oxygen use. Routine use of concurrently administered dopamine with vasopressors is not recommended. Phenylephrine should be used when a pure vasoconstrictor is desired in patients who may not require or do not tolerate the beta (β ) effects of dopamine or norepinephrine with or without dobutamine. Patients with high filling pressure and hypotension may benefit from the combination of phenylephrine and dobutamine. Investigational approaches to vasopressor-refractory hypotension in septic shock include the use of vasopressin and corticosteroids.
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Affiliation(s)
- Maria I. Rudis
- USC Schools of Pharmacy and Medicine, 1985 Zonal Avenue, PSC 700, Los Angeles, CA 90033,
| | - Clarence Chant
- St. Michael’s Hospital and University of Toronto Faculty of Pharmacy, Toronto, ON, Canada
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21
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Jones D, Bellomo R. Renal-Dose Dopamine: From Hypothesis to Paradigm to Dogma to Myth and, Finally, Superstition? J Intensive Care Med 2016; 20:199-211. [PMID: 16061903 DOI: 10.1177/0885066605276963] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Acute renal failure (ARF) is common in the critically ill and is associated with a high mortality rate. Its pathogenesis is not understood. Because animal models use ischemia to induce experimental ARF, there is the widespread belief that lack of blood flow is responsible for ARF. Low-dose dopamine (LDD) has been shown to increase renal blood flow in animal and in human volunteers. Thus, it has been administered to humans for almost 3 decades in the belief that it would lead to renal arterial vasodilation and increase renal blood flow (RBF). However, the etiology of ARF in critical illness is likely multifactorial, and the contribution of hypovolemia and reduced renal perfusion is unknown. Furthermore, interindividual variation in the pharmacokinetics of dopamine typically results in poor correlation between blood levels and administered dose, making accurate and reliable delivery of LDD difficult. Finally, dopamine is a proximal tubular diuretic that increases Na+ delivery to tubular cells, thus increasing their oxygen demands. Accordingly, even if LDD were able to preferentially increase RBF, there is no guarantee that it would restore renal parenchymal oxygen homeostasis. More important, 2 meta-analyses and a large double-blind, prospective, multiple-center, randomized controlled trial have failed to demonstrate that dopamine protects the kidney in critically ill patients with ARF. Currently, there is insufficient evidence to support the use of renal-dose dopamine in the intensive care unit.
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Affiliation(s)
- Daryl Jones
- Department of Intensive Care, Melbourne University, Austin Hospital, Melbourne, Australia
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22
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ŠÍMA M, POKORNÁ P, HRONOVÁ K, SLANAŘ O. Effect of Co-Medication on the Pharmacokinetic Parameters of Phenobarbital in Asphyxiated Newborns. Physiol Res 2015; 64:S513-9. [DOI: 10.33549/physiolres.933213] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Phenobarbital is an anticonvulsive drug widely used in newborns with hypoxic-ischemic encephalopathy. The objective of our study was to describe possible effect of frequently co-administered medications (dopamine, dobutamine, norepinephrine, furosemide, phenytoin, and analgesics) on the phenobarbital pharmacokinetics in full term newborns with hypoxic-ischemic encephalopathy. Phenobarbital pharmacokinetic parameters (standardized intravenous loading dose was 10-20 mg/kg, maintenance dose 2-6 mg/kg/day) were computed using non-compartmental analysis. Co-medication was evaluated throughout the whole treatment period up to 5 days. Volume of distribution, clearance, and half-life median values (95 % CI) for phenobarbital in the whole study population (n=37) were 0.48 (0.41-0.56) l/kg, 0.0034 (0.0028-0.0040) l/h/kg, and 93.7 (88.1-99.2) h, respectively. Phenobarbital pharmacokinetic parameters were not significantly affected by vasoactive drugs (dopamine, dobutamine, and norepinephrine), furosemide, phenytoin, or analgesics. Furthermore, no dose-dependent alteration of phenobarbital pharmacokinetic parameters was noted for vasoactive medication at doses equivalent to cumulative vasoactive-inotropic score (area under the curve in a plot of vasoactive-inotropic score against time) 143.2-8473.6, furosemide at cumulative doses of 0.2-42.9 mg/kg, or phenytoin at cumulative doses of 10.3-46.2 mg/kg. Phenobarbital pharmacokinetics was not affected by investigated co-administered drugs used in newborns with hypoxic-ischemic encephalopathy in real clinical settings.
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Affiliation(s)
- M. ŠÍMA
- Department of Pharmacology, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Czech Republic
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23
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Cândido TD, Teixeira-Neto FJ, Diniz MS, Zanuzzo FS, Teixeira LR, Fantoni DT. Effects of a dexmedetomidine constant rate infusion and atropine on changes in global perfusion variables induced by hemorrhage followed by volume replacement in isoflurane-anesthetized dogs. Am J Vet Res 2015; 75:964-73. [PMID: 25350086 DOI: 10.2460/ajvr.75.11.964] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To evaluate the effects of a dexmedetomidine constant rate infusion (CRI) and atropine on changes in global perfusion variables induced by hemorrhage and volume replacement (VR) in isoflurane-anesthetized dogs. ANIMALS 8 adult dogs. PROCEDURES Each dog was anesthetized twice, with a 2-week interval between anesthetic sessions. Anesthesia was maintained with 1.3 times the minimum alveolar concentration of isoflurane with and without dexmedetomidine (1.6 μg/kg, IV bolus, followed by 2 μg/kg/h, CRI). Dogs were mechanically ventilated and received an atracurium neuromuscular blockade during both sessions. During anesthesia with isoflurane and dexmedetomidine, atropine was administered 30 minutes before baseline measurements were obtained. After baseline data were recorded, 30% of the total blood volume was progressively withdrawn and VR was achieved with an equal proportion of autologous blood. RESULTS Following hemorrhage, cardiac index, oxygen delivery index, and mixed-venous oxygen saturation were significantly decreased and the oxygen extraction ratio was significantly increased from baseline. The anaerobic threshold was not achieved during either anesthetic session. When dogs were anesthetized with isoflurane and dexmedetomidine, they had a significantly lower heart rate, cardiac index, and mixed-venous oxygen saturation during VR than they did when anesthetized with isoflurane alone. Plasma lactate concentration, mixed venous-to-arterial carbon dioxide difference, base excess, and anion gap were unaltered by hemorrhage and VR and did not differ between anesthetic sessions. CONCLUSIONS AND CLINICAL RELEVANCE Results indicated that the use of a dexmedetomidine CRI combined with atropine in isoflurane-anesthetized dogs that underwent volume-controlled hemorrhage followed by VR did not compromise global perfusion sufficiently to result in anaerobic metabolism.
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Affiliation(s)
- Thaísa D Cândido
- Departments of Anesthesiology, São Paulo State University, Botucatu, SP, 18618-970, Brazil
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Chakravarty A, Anand S, Sapra H, Mehta Y. Undetected hypoparathyroidism: An unusual cause of perioperative morbidity. Indian J Anaesth 2014; 58:470-2. [PMID: 25197121 PMCID: PMC4155298 DOI: 10.4103/0019-5049.139014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Routine investigation of serum calcium is not recommended in ASA one and two patients unless abnormalities of calcium metabolism are clinically suspected. The clinical features of hypocalcaemia can often be subtle and may manifest in the presence of associated factors. Hypoparathyroidism, an important cause of hypocalcaemia, often presents as soft tissue calcification (ostosis). Ligamentum flavum ostosis can present with compressive myelopathy requiring laminectomy. We report a case of ligamentum flavum ostosis and subclinical hypocalcaemia due to hypoparathyroidism, who went undetected pre-operatively resulting in significant post-operative morbidity.
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Affiliation(s)
- Ashish Chakravarty
- Department of Neuroanaesthesiology and Critical Care, Medanta, The Medicity, Gurgaon, Haryana, India
| | - Saurabh Anand
- Department of Neuroanaesthesiology and Critical Care, Medanta, The Medicity, Gurgaon, Haryana, India
| | - Harsh Sapra
- Department of Neuroanaesthesiology and Critical Care, Medanta, The Medicity, Gurgaon, Haryana, India
| | - Yatin Mehta
- Department of Neuroanaesthesiology and Critical Care, Medanta, The Medicity, Gurgaon, Haryana, India
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Poukkanen M, Wilkman E, Vaara ST, Pettilä V, Kaukonen KM, Korhonen AM, Uusaro A, Hovilehto S, Inkinen O, Laru-Sompa R, Hautamäki R, Kuitunen A, Karlsson S. Hemodynamic variables and progression of acute kidney injury in critically ill patients with severe sepsis: data from the prospective observational FINNAKI study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:R295. [PMID: 24330815 PMCID: PMC4056430 DOI: 10.1186/cc13161] [Citation(s) in RCA: 108] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/24/2013] [Accepted: 11/14/2013] [Indexed: 12/26/2022]
Abstract
Introduction Knowledge of the association of hemodynamics with progression of septic acute kidney injury (AKI) is limited. However, some recent data suggest that mean arterial pressure (MAP) exceeding current guidelines (60–65 mmHg) may be needed to prevent AKI. We hypothesized that higher MAP during the first 24 hours in the intensive care unit (ICU), would be associated with a lower risk of progression of AKI in patients with severe sepsis. Methods We identified 423 patients with severe sepsis and electronically recorded continuous hemodynamic data in the prospective observational FINNAKI study. The primary endpoint was progression of AKI within the first 5 days of ICU admission defined as new onset or worsening of AKI by the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. We evaluated the association of hemodynamic variables with this endpoint. We included 53724 10-minute medians of MAP in the analysis. We analysed the ability of time-adjusted MAP to predict progression of AKI by receiver operating characteristic (ROC) analysis. Results Of 423 patients, 153 (36.2%) had progression of AKI. Patients with progression of AKI had significantly lower time-adjusted MAP, 74.4 mmHg [68.3-80.8], than those without progression, 78.6 mmHg [72.9-85.4], P < 0.001. A cut-off value of 73 mmHg for time-adjusted MAP best predicted the progression of AKI. Chronic kidney disease, higher lactate, higher dose of furosemide, use of dobutamine and time-adjusted MAP below 73 mmHg were independent predictors of progression of AKI. Conclusions The findings of this large prospective multicenter observational study suggest that hypotensive episodes (MAP under 73 mmHg) are associated with progression of AKI in critically ill patients with severe sepsis.
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Ricksten SE, Bragadottir G, Redfors B. Renal oxygenation in clinical acute kidney injury. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:221. [PMID: 23514538 PMCID: PMC3672481 DOI: 10.1186/cc12530] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Beloncle F, Duveau A, Burban M, Lerolle N, Asfar P. Quels sont les objectifs hémodynamiques pour le rein au cours du choc septique ? MEDECINE INTENSIVE REANIMATION 2013. [DOI: 10.1007/s13546-012-0635-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Broomhead RH, Patel S, Fernando B, O'Beirne J, Mallett S. Resource implications of expanding the use of donation after circulatory determination of death in liver transplantation. Liver Transpl 2012; 18:771-8. [PMID: 22315207 DOI: 10.1002/lt.23406] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
In the United Kingdom, liver transplantation using donation after circulatory determination of death (DCDD) organs has increased steadily over the last few years and now accounts for 20% of UK transplant activity. The procurement of DCDD livers is actively promoted as a means of increasing the donor pool and bridging the evolving disparity between the wait-list length and the number of transplants performed. The objective of this retrospective study of a cohort of patients who were matched for age, liver disease etiology, and Model for End-Stage Liver Disease score was to determine whether differences in perioperative costs and resource utilization are associated with the use of such organs. Our results showed an increased prevalence of reperfusion syndrome in the DCDD cohort (P < 0.001), a prolonged heparin effect (P = 0.01), a greater incidence of hyperfibrinolysis (P = 0.002), longer periods of postoperative ventilator use (P = 0.03) and vasopressor support (P = 0.002), and a prolonged length of stay in the intensive therapy unit (ITU; P = 0.02). The peak posttransplant aspartate aminotransferase level was higher in the DCDD group (P = 0.007), and there was significantly more graft failure at 12 months (P = 0.03). In conclusion, we have demonstrated different perioperative and early postoperative courses for DCDD and donation after brain death (DBD) liver transplants. The overall quality of DCDD grafts is poorer; as a result, the length of the ITU stay and the need for multiorgan support are increased, and this has significant financial and resource implications. We believe that these implications require a careful real-life consideration of benefits. It is essential for DCDD not to be seen as a like-for-like alternative to DBD and for every effort to be continued to be made to increase the number of donations from brain-dead patients as a first resort.
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Giamouzis G, Butler J, Starling RC, Karayannis G, Nastas J, Parisis C, Rovithis D, Economou D, Savvatis K, Kirlidis T, Tsaknakis T, Skoularigis J, Westermann D, Tschöpe C, Triposkiadis F. Impact of dopamine infusion on renal function in hospitalized heart failure patients: results of the Dopamine in Acute Decompensated Heart Failure (DAD-HF) Trial. J Card Fail 2011; 16:922-30. [PMID: 21111980 DOI: 10.1016/j.cardfail.2010.07.246] [Citation(s) in RCA: 136] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2010] [Revised: 05/29/2010] [Accepted: 07/07/2010] [Indexed: 12/20/2022]
Abstract
BACKGROUND Worsening renal function (WRF) and hypokalemia related to diuretic use for acute decompensated heart failure (ADHF) are common and associated with poor prognosis. Low-dose dopamine infusion improves renal perfusion; its effect on diuresis or renal function specifically in ADHF is not known. METHODS AND RESULTS Sixty consecutive ADHF patients (age 75.7 ± 11.2 years; 51.7% female; left ventricular ejection fraction 35.3 ± 12.1%) were randomized, after receiving a 40 mg intravenous furosemide bolus, to either high-dose furosemide (HDF, 20 mg/h continuous infusion for 8 hours) or low-dose furosemide combined with low-dose dopamine (LDFD, furosemide 5 mg/h plus dopamine 5 μg kg(-1) min(-1) continuous infusion for 8 hours). Both strategies were compared for total diuresis, WRF (defined as a rise in serum creatinine of >0.3 mg/dL from baseline to 24 hours), electrolyte balance, and 60-day postdischarge outcomes. Mean hourly excreted urine volume (272 ± 149 mL in HDF vs 278 ± 186 mL in LDFD group; P = .965) and changes in dyspnea score (Borg index: -4.4 ± 2.1 in HDF group vs -4.7 ± 2.0 in LDFD group; P = .575) during the 8 hours of protocol treatment were similar in the two groups. WRF was more frequent in the HDF (n = 9; 30%) than in the LDFD group (n = 2; 6.7%; P = .042). Serum potassium changed from 4.3 ± 0.5 to 3.9 ± 0.4 mEq/L at 24 hours (P = .003) in the HDF group and from 4.4 ± 0.5 to 4.2 ± 0.5 mEq/L at 24 hours (P = .07) in the LDFD group. Length of stay and 60-day mortality or rehospitalization rates (all-cause, cardiovascular, and worsening HF) were similar in the two groups. CONCLUSIONS In ADHF patients, the combination of low-dose furosemide and low-dose dopamine is equally effective as high-dose furosemide but associated with improved renal function profile and potassium homeostasis.
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Affiliation(s)
- Gregory Giamouzis
- Department of Cardiology, Larissa University Hospital, Larissa, Greece
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Nohé B, Ploppa A, Schmidt V, Unertl K. [Volume replacement in intensive care medicine]. Anaesthesist 2011; 60:457-64, 466-73. [PMID: 21350879 DOI: 10.1007/s00101-011-1860-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Volume substitution represents an essential component of intensive care medicine. The amount of fluid administered, the composition and the timing of volume replacement seem to affect the morbidity and mortality of critically ill patients. Although restrictive volume strategies bear the risk of tissue hypoperfusion and tissue hypoxia in hemodynamically unstable patients liberal strategies favour the development of avoidable hypervolemia with edema and resultant organ dysfunction. However, neither strategy has shown a consistent benefit. In order to account for the heavily varying oxygen demand of critically ill patients, a goal-directed, demand-adapted volume strategy is proposed. Using this strategy, volume replacement should be aligned to the need to restore tissue perfusion and the evidence of volume responsiveness. As the efficiency of volume resuscitation for correction of tissue hypoxia is time-dependent, preload optimization should be completed in the very first hours. Whether colloids or crystalloids are more suitable for this purpose is still controversially discussed. Nevertheless, a temporally limited use of colloids during the initial stage of tissue hypoperfusion appears to represent a strategy which uses the greater volume effect during hypovolemia while minimizing the risks for adverse reactions.
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Affiliation(s)
- B Nohé
- Klinik für Anaesthesiologie und Intensivmedizin, Universitätsklinikum Tübingen, Deutschland.
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SEPSISPAM : évaluation de l’effet de deux niveaux de pression artérielle sur la survie des patients en choc septique. MEDECINE INTENSIVE REANIMATION 2011. [DOI: 10.1007/s13546-011-0221-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Redfors B, Bragadottir G, Sellgren J, Swärd K, Ricksten SE. Effects of norepinephrine on renal perfusion, filtration and oxygenation in vasodilatory shock and acute kidney injury. Intensive Care Med 2010; 37:60-7. [PMID: 20949349 DOI: 10.1007/s00134-010-2057-4] [Citation(s) in RCA: 108] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2010] [Accepted: 09/21/2010] [Indexed: 01/17/2023]
Affiliation(s)
- Bengt Redfors
- Department of Cardiothoracic Anaesthesia and Intensive Care, Sahlgrenska University Hospital, 413 45 Gothenburg, Sweden
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Redfors B, Bragadottir G, Sellgren J, Swärd K, Ricksten SE. Dopamine increases renal oxygenation: a clinical study in post-cardiac surgery patients. Acta Anaesthesiol Scand 2010; 54:183-90. [PMID: 19764906 DOI: 10.1111/j.1399-6576.2009.02121.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Imbalance of the renal medullary oxygen supply/demand relationship can cause ischaemic acute renal failure (ARF). The use of dopamine for prevention/treatment of ischaemic ARF has been questioned. It has been suggested that dopamine may increase renal oxygen consumption (RVO(2)) due to increased solute delivery to tubular cells, which may jeopardize renal oxygenation. Information on the effects of dopamine on renal perfusion, filtration and oxygenation in man is, however, lacking. We evaluated the effects of dopamine on renal blood flow (RBF), glomerular filtration rate (GFR), RVO(2) and renal O(2) demand/supply relationship, i.e. renal oxygen extraction (RO(2)Ex). METHODS Twelve uncomplicated, mechanically ventilated and sedated post-cardiac surgery patients with pre-operatively normal renal function were studied. Dopamine was sequentially infused at 2 and 4 ug/kg/min. Systemic haemodynamics were evaluated by a pulmonary artery catheter. Absolute RBF was measured using two independent techniques: by the renal vein thermodilution technique and by infusion clearance of paraaminohippuric acid (PAH), with a correction for renal extraction of PAH. The filtration fraction (FF) was measured by the renal extraction of (51)Cr-EDTA. RESULTS Neither GFR, tubular sodium reabsorption nor RVO(2) was affected by dopamine, which increased RBF (45-55%) with both methods, decreased renal vascular resistance (30-35%), FF (21-26%) and RO(2)Ex (28-34%). The RBF/CI ratio increased with dopamine. Dopamine decreased renal PAH extraction, suggestive of a flow distribution to the medulla. CONCLUSIONS In post-cardiac surgery patients, dopamine increases the renal oxygenation by a pronounced renal pre-and post-glomerular vasodilation with no increases in GFR, tubular sodium reabsorption or renal oxygen consumption.
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Affiliation(s)
- Bengt Redfors
- Department of Cardiothoracic Anesthesia and Intensive Care, Sahlgrenska University Hospital, Göteborg, Sweden
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Abstract
Septic shock, systemic inflammation and pharmacological vasodilatation are often complicated by systemic hypotension despite aggressive fluid resuscitation and an increased cardiac output. If the physician wishes to restore arterial pressure to higher levels (> 80-85 mmHg), with the aim of sustaining cerebral and coronary perfusion pressure, the administration of systemic vasopressor agents, such as norepinephrine (noradrenaline), becomes necessary. However, because norepinephrine (NE) induces vasoconstriction in many vascular beds (visibly in the skin), it may decrease renal and visceral blood flow, impairing visceral organ function. This unproven fear deters clinicians from using NE more consistently. Vasodilated states, however, are often associated with impaired peripheral vascular responsiveness. In such states, unlike under normal circulatory conditions, NE may actually improve visceral organ blood flow by selectively increasing organ perfusion pressure. Data available from animal studies show that the increased organ perfusion pressures achieved with NE results in improved GFR and renal blood flow. In fact, recent sophisticated physiological analysis of its effects on the kidney shows that, even after controlling for the pressure effect, NE therapy is associated with an increase in renal blood flow after endotoxin administration. In particular, the renal Pzf (pressure at which there is no further blood flow) is decreased such that, at a constant pressure, renal blood flow increases after NE. There are no controlled human data to define the effects of NE on the kidney in the clinical context. However, many patient series have now been reported. They show a seemingly positive effect of NE administration on GFR and urine output. Our clinical experience in septic patients and cardiac patients with inflammatory or pharmacological vasodilatation is also positive. We have demonstrated a positive effect on coronary blood flow. There is no reason to fear the effect of NE. If it is used to support a vasodilated circulation after adequate intravascular filling has occurred and after a normal or increased cardiac output has been established, it is likely to be a friend not a foe.
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Affiliation(s)
- Rinaldo Bellomo
- Department of Intensive Care and Medicine, Austin & Repatriation Medical Centre, Melbourne, Australia.
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Prowle JR, Echeverri JE, Ligabo EV, Ronco C, Bellomo R. Fluid balance and acute kidney injury. Nat Rev Nephrol 2009; 6:107-15. [PMID: 20027192 DOI: 10.1038/nrneph.2009.213] [Citation(s) in RCA: 289] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Intravenous fluids are widely administered to patients who have, or are at risk of, acute kidney injury (AKI). However, deleterious consequences of overzealous fluid therapy are increasingly being recognized. Salt and water overload can predispose to organ dysfunction, impaired wound healing and nosocomial infection, particularly in patients with AKI, in whom fluid challenges are frequent and excretion is impaired. In this Review article, we discuss how interstitial edema can further delay renal recovery and why conservative fluid strategies are now being advocated. Applying these strategies in critical illness is challenging. Although volume resuscitation is needed to restore cardiac output, it often leads to tissue edema, thereby contributing to ongoing organ dysfunction. Conservative strategies of fluid management mandate a switch towards neutral balance and then negative balance once hemodynamic stabilization is achieved. In patients with AKI, this strategy might require renal replacement therapy to be given earlier than when more-liberal fluid management is used. However, hypovolemia and renal hypoperfusion can occur in patients with AKI if excessive fluid removal is pursued with diuretics or extracorporeal therapy. Thus, accurate assessment of fluid status and careful definition of targets are needed at all stages to improve clinical outcomes. A conservative strategy of fluid management was recently tested and found to be effective in a large, randomized, controlled trial in patients with acute lung injury. Similar randomized, controlled studies in patients with AKI now seem justified.
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Affiliation(s)
- John R Prowle
- Department of Intensive Care, Austin Health, 145 Studley Road Heidelberg, Vic 3084, Australia
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Rauen CA, Makic MBF, Bridges E. Evidence-based practice habits: transforming research into bedside practice. Crit Care Nurse 2009; 29:46-59; quiz 60-61. [PMID: 19339447 DOI: 10.4037/ccn2009287] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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Hollis A, Ousey J, Palmer L, Stephen J, Stoneham S, Boston R, Corley K. Effects of Norepinephrine and Combined Norepinephrine and Fenoldopam Infusion on Systemic Hemodynamics and Indices of Renal Function in Normotensive Neonatal Foals. J Vet Intern Med 2008; 22:1210-5. [DOI: 10.1111/j.1939-1676.2008.0146.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Meier J, Pape A, Loniewska D, Lauscher P, Kertscho H, Zwissler B, Habler O. Norepinephrine increases tolerance to acute anemia. Crit Care Med 2007; 35:1484-92. [PMID: 17452931 DOI: 10.1097/01.ccm.0000265740.62130.1c] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Extreme anemia threatens myocardial oxygen supply by 1) a decline of arterial oxygen content and 2) by a decline of mean aortic pressure (MAP) and thus coronary perfusion pressure. Standard treatment of low arterial oxygen content includes ventilation with pure oxygen and the transfusion of red blood cells. However, it is unknown whether the stabilization of MAP and coronary perfusion pressure with norepinephrine as the sole therapeutic modality may also increase tolerance to extreme anemia and thus improve outcome. DESIGN Prospective, randomized, controlled study. SETTING Experimental animal laboratory of a university hospital. SUBJECTS A total of 28 anesthetized, mechanically ventilated pigs. INTERVENTIONS AND MEASUREMENTS In the first protocol, 14 anesthetized pigs were hemodiluted by exchange of whole blood for 6% hydroxyethyl starch (200,000:0.5) until the individual critical hemoglobin concentration was reached. For the next 6 hrs, animals were either observed without any further intervention (control group) or their MAP was maintained by adapted infusion of norepinephrine (norepinephrine group). The main outcome variable of this protocol was the 6-hr mortality in both groups. In the second protocol, 14 anesthetized pigs received hemodilution until death. In seven animals, no intervention was performed during the hemodilution procedure, whereas in the other seven animals, MAP was maintained at >60 mm Hg by adapted infusion of norepinephrine. The main outcome variable of this protocol was the maximum exchangeable blood volume until death. MAIN RESULTS MAP stabilization with norepinephrine reduced the 6-hr mortality at the critical hemoglobin concentration from 100% to 14%. Maintaining MAP by adapted norepinephrine infusion during the hemodilution procedure allowed for the exchange of 125 (110/126) (median [quartile 1/quartile 3]) mL/kg blood (163% of blood volume) in the norepinephrine group, whereas only 76 (73/91) mL/kg blood (104% of blood volume) could be exchanged in the control group. CONCLUSIONS Application of norepinephrine can be judged a first-line intervention to bridge acute anemia via a stabilization of MAP and coronary perfusion pressure. However, due to the relevant side effects of norepinephrine, its sole long-term use during extreme anemia without concomitant transfusion of erythrocytes is not advised.
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Affiliation(s)
- Jens Meier
- Department of Anesthesiology, Intensive Care Medicine, and Pain Control, J. W. Goethe-University Hospital, Frankfurt, Germany.
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Hollis A, Ousey J, Palmer L, Stoneham S, Corley K. Effects of Norepinephrine and a Combined Norepinephrine and Dobutamine Infusion on Systemic Hemodynamics and Indices of Renal Function in Normotensive Neonatal Thoroughbred Foals. J Vet Intern Med 2006. [DOI: 10.1111/j.1939-1676.2006.tb00763.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
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Izikson L, English JC, Zirwas MJ. The flushing patient: Differential diagnosis, workup, and treatment. J Am Acad Dermatol 2006; 55:193-208. [PMID: 16844500 DOI: 10.1016/j.jaad.2005.07.057] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2005] [Revised: 06/09/2005] [Accepted: 07/23/2005] [Indexed: 01/04/2023]
Abstract
UNLABELLED Cutaneous flushing-a common presenting complaint to dermatologists, allergists, internists, and family practitioners-results from changes in cutaneous blood flow triggered by multiple conditions. Most cases are caused by very common, benign diseases, such as rosacea or climacterum, that are readily apparent after a thorough taking of history and physical examination. However, in some cases, accurate diagnosis requires further laboratory, radiologic, or histopathologic studies to differentiate several important clinicopathologic entities. In particular, the serious diagnoses of carcinoid syndrome, pheochromocytoma, mastocytosis, and anaphylaxis need to be excluded by laboratory studies. If this work-up is unrevealing, rare causes, such as medullary carcinoma of the thyroid, pancreatic cell tumor, renal carcinoma, and others, should be considered. LEARNING OBJECTIVE At the completion of this learning activity, participants should be familiar with the mechanisms of flushing, its clinical differential diagnosis, the approach to establish a definitive diagnosis, and management of various conditions that produce flushing.
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Affiliation(s)
- Leonid Izikson
- Department of Dermatology, University of Pittsburgh Medical Center, Pennsylvania, USA
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Lauschke A, Teichgräber UKM, Frei U, Eckardt KU. 'Low-dose' dopamine worsens renal perfusion in patients with acute renal failure. Kidney Int 2006; 69:1669-74. [PMID: 16572117 DOI: 10.1038/sj.ki.5000310] [Citation(s) in RCA: 172] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
'Low-dose' dopamine is frequently used in intensive care units (ICU) for its presumed renoprotective effects, but prospective and retrospective studies have so far not proven prevention or amelioration of renal injury. Data on renal perfusion following dopamine infusion are limited. In order to circumvent the problem of patient heterogeneity in the ICU setting, we used a crossover design in a prospective, double-blind randomized controlled study to investigate the effect of 'low-dose' dopamine on renal resistance indices, as determined by Doppler ultrasound. Forty patients, 10 without and 30 with acute renal failure (ARF, defined as doubling of baseline creatinine or an increase above 2 mg/dl), were included. Dopamine (2 mug/kg min) or placebo was given intravenously in alternating sequence for four subsequent periods of 60 min, starting randomly with either dopamine or placebo. Resistive (RI) and pulsatility index (PI) were closely correlated, positively related to serum creatinine values at baseline and highly reproducible during the two paired infusion periods. Dopamine reduced renal vascular resistance in patients without ARF (median RI/PI from 0.70 to 0.65/1.20 to 1.07, P<0.01) but increased resistance indices in patients with ARF (median RI/PI from 0.77 to 0.81/1.64 to 1.79, P<0.01) in the absence of effects on systemic hemodynamics. Subgroup analysis of patients with ARF revealed that dopamine induced renal vasoconstriction above 55 years (n=22) and in patients not receiving norepinephrine (n=20). In conclusion 'low-dose' dopamine can worsen renal perfusion in patients with ARF, which adds to the rationale for abandoning the routine use of 'low-dose' dopamine in critically ill patients.
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Affiliation(s)
- A Lauschke
- Department of Nephrology and Medical Intensive Care, Charité University Medicine, Berlin, Germany
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Abstract
Acute renal failure (ARF) in patients in the ICU is associated with a high mortality. Drug-induced renal dysfunction is an important, yet often overlooked, cause of ARF in this patient population. A drug use evaluation at the authors' institution, to assess the prescribing patterns of potential nephrotoxins in the adult and pediatric ICUs, found that antibiotics (aminoglycosides, amphotericin B, penicillins, cephalosporins, acyclovir), nonsteroidal anti-inflammatory drugs, contrast dye, and various other nephrotoxic medications are used widely in all of the ICUs. By focusing on several commonly prescribed classes of nephrotoxic medications in the ICU, this article reviews the general mechanisms of drug-associated renal dysfunction.
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Affiliation(s)
- Stephanie S Taber
- Department of Clinical Sciences, University of Michigan College of Pharmacy, 1500 East Medical Center Drive, UHB2D301 Box 0008, Ann Arbor, MI 48109, USA.
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Peng ZY, Critchley LAH, Fok BSP. The effects of increasing doses of noradrenaline on systemic and renal circulations in acute bacteraemic dogs. Intensive Care Med 2005; 31:1558-63. [PMID: 16088408 DOI: 10.1007/s00134-005-2741-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2004] [Accepted: 06/27/2005] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To determine the dose-response effects of noradrenaline on the systemic and renal circulations during septic shock. DESIGN AND SETTING Prospective controlled experiment in a university animal laboratory. SUBJECTS Eight anaesthetized dogs. INTERVENTIONS Transonic flow probes were surgically placed on the aorta via a left lateral thoracotomy and on the left renal artery. Blood pressure was measured from the femoral artery. Acute bacteraemia shock was induced by injecting Escherichia coli bacteria intravenously. Increasing doses of noradrenaline (0.1, 0.2, 0.3, 0.4, 0.5 microg kg(-1) min(-1)) were infused intravenously for 30 min at 30-min intervals. The model was first validated in four dogs. MEASUREMENTS AND RESULTS Mean arterial pressure, central venous pressure, cardiac output, and renal blood flow were measured. Systemic vascular resistance was derived. Induction of bacteraemia decreased mean arterial pressure, central venous pressure and systemic vascular resistance. Cardiac output slightly increased. Noradrenaline produced linear dose-dependent increases in both mean arterial pressure and systemic vascular resistance. The response was attenuated during bacteraemia. Under non-bacteraemic conditions the maximum dose of noradrenaline reduced the renal blood flow from 12+/-1 to 10+/-1 ml kg(-1) min(-1). Bacteraemia further reduced renal blood flow to 7+/-1 ml kg(-1) min(-1), which was partly restored by the maximum dose of noradrenaline to 11+/-3 ml kg(-1) min(-1). CONCLUSIONS Noradrenaline can restore mean arterial pressure in bacteraemic shock and increases in mean arterial pressure are dose-dependent. The noradrenaline response is attenuated by bacteraemic shock. In bacteraemic shock noradrenaline also improves renal perfusion, as perfusion pressure increases. However, renal blood flow is not fully restored, suggesting that an element of impairment of renal blood flow exists due to the bacteraemia or noradrenaline.
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Affiliation(s)
- Zhi-Yong Peng
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, China
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Regner KR, Connolly HM, Schaff HV, Albright RC. Acute Renal Failure After Cardiac Surgery for Carcinoid Heart Disease: Incidence, Risk Factors, and Prognosis. Am J Kidney Dis 2005; 45:826-32. [PMID: 15861347 DOI: 10.1053/j.ajkd.2005.02.009] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Cardiac surgery for carcinoid heart disease may be associated with acute renal failure (ARF) and multiorgan dysfunction postoperatively. This study was performed to determine the incidence, risk factors, and prognosis of ARF after cardiac surgery for carcinoid heart disease. METHODS This is a case-control study of 86 consecutive patients who underwent cardiac surgery for carcinoid heart disease. ARF is defined as hemodialysis requirement or serum creatinine level 50% greater than baseline, resulting in an estimated creatinine clearance less than 40 mL/min (0.67 mL/s). Preoperative, operative, and postoperative characteristics were examined and compared between groups to determine risk factors and prognosis of ARF. RESULTS ARF occurred in 22% of cases (19 of 86 patients). Preoperative characteristics and type of procedure did not differ between groups. Operative variables associated with ARF by means of univariate analysis included longer surgical and bypass times, intra-aortic balloon pump use, and perioperative epinephrine requirement. Postoperatively, ARF was associated with epinephrine use, prolonged mechanical ventilation, prolonged intensive care unit admission, and higher Acute Physiology and Chronic Health Evaluation II scores. Perioperative mortality in the ARF group was 47% versus 4.5% in the control group (odds ratio, 36.1; 95% confidence interval, 8.0 to 261.8). CONCLUSION ARF developed in a relatively high proportion of this cohort, but traditional preoperative risks failed to predict post-cardiac surgery ARF. Variables closely related to perioperative hemodynamic compromise were associated with ARF. ARF portends a particularly poor prognosis in this cohort that is explained largely by multiorgan failure syndrome.
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Affiliation(s)
- Kevin R Regner
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA.
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Lameire N. [Which are the therapeutic interventions allowing to ensure a protection of the renal function?]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2005; 24:206-21. [PMID: 15737508 DOI: 10.1016/j.annfar.2004.12.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Affiliation(s)
- N Lameire
- Service de néphrologie, faculté de médecine, hôpital universitaire Gand-De-Pintelaan, 185, 9000 Gent, Belgique.
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Beale RJ, Hollenberg SM, Vincent JL, Parrillo JE. Vasopressor and inotropic support in septic shock: An evidence-based review. Crit Care Med 2004; 32:S455-65. [PMID: 15542956 DOI: 10.1097/01.ccm.0000142909.86238.b1] [Citation(s) in RCA: 149] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE In 2003, critical care and infectious disease experts representing 11 international organizations developed management guidelines for vasopressor and inotropic support in septic shock that would be of practical use for the bedside clinician, under the auspices of the Surviving Sepsis Campaign, an international effort to increase awareness and to improve outcome in severe sepsis. DESIGN The process included a modified Delphi method, a consensus conference, several subsequent smaller meetings of subgroups and key individuals, teleconferences, and electronic-based discussion among subgroups and among the entire committee. METHODS The modified Delphi methodology used for grading recommendations built on a 2001 publication sponsored by the International Sepsis Forum. We undertook a systematic review of the literature graded along five levels to create recommendation grades from A to E, with A being the highest grade. Pediatric considerations to contrast adult and pediatric management are in the article by Parker et al. on p. S591. CONCLUSION An arterial catheter should be placed as soon as possible in patients with septic shock. Vasopressors are indicated to maintain mean arterial pressure of <65 mm Hg, both during and following adequate fluid resuscitation. Norepinephrine or dopamine are the vasopressors of choice in the treatment of septic shock. Norepinephrine may be combined with dobutamine when cardiac output is being measured. Epinephrine, phenylephrine, and vasopressin are not recommended as first-line agents in the treatment of septic shock. Vasopressin may be considered for salvage therapy. Low-dose dopamine is not recommended for the purpose of renal protection. Dobutamine is recommended as the agent of choice to increase cardiac output but should not be used for the purpose of increasing cardiac output above physiologic levels.
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Pereira CN, Machado FR, Guimarães HP, Senna APR, do Amaral JLG. Hemodynamics and renal function during administration of low-dose dopamine in severely ill patients. SAO PAULO MED J 2004; 122:141-6. [PMID: 15543367 DOI: 10.1590/s1516-31802004000400002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
CONTEXT Although a large number of studies have been performed regarding the renal and hemodynamic effects of the infusion of low-dose dopamine (LDD) in severely ill patients, there is still controversy on this subject. OBJECTIVE To evaluate the effects of dopamine (2 microg/kg/min) on systemic hemodynamics (lowest mean arterial pressure, MAP, highest heart rate, HR, central venous pressure, CVP), creatinine clearance (CLcr), diuresis and fractional sodium excretion (FENa+). TYPE OF STUDY A non-randomized, open, prospective clinical trial. SETTING An intensive care unit in a tertiary university hospital. PARTICIPANTS 22 patients with hemodynamic stability admitted to the intensive care unit. PROCEDURES Patients were submitted to three two-hour periods: without dopamine (P1), with dopamine (P2) and without dopamine (P3). MAIN MEASUREMENTS The above mentioned variables were measured during each period. CLcr was assessed based upon the formula U x V/P, where U is urinary creatinine (mg/dl), V is diuresis in ml/min and P is serum creatinine (mg/dl). FENa+ was calculated based upon the formula: urinary sodium (mEq/l) x P/plasma sodium (mEq/l) x U) x 100. Results were presented as mean and standard deviation. The Student t test was used and results were considered significant if p was less than 0.05. RESULTS Twelve patients (seven males and five females) were included, with a mean age of 55.45 years. There was no significant variation in MAP, HR, CVP, CLcr or FENa+ with a dopamine dose of 2 microg/kg/min. On the other hand, diuresis significantly increased during P2, from 225.4 to 333.9 ml. CONCLUSION Infusion of 2 microg/kg/min of dopamine for 2 hours increases diuresis. At the doses studied, dopamine does not induce significant alterations in MAP, HR, CVP, CLcr and FENa+.
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Affiliation(s)
- Cláudia Nathalie Pereira
- Intensive Care Unit, Discipline of Anesthesiology, Pain and Intensive Care, Universidade Federal de São Paulo, São Paulo, Brazil
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