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Gaspar HA, Morhy SS, Lianza AC, de Carvalho WB, Andrade JL, do Prado RR, Schvartsman C, Delgado AF. Focused cardiac ultrasound: a training course for pediatric intensivists and emergency physicians. BMC MEDICAL EDUCATION 2014; 14:25. [PMID: 24502581 PMCID: PMC3926333 DOI: 10.1186/1472-6920-14-25] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Accepted: 02/03/2014] [Indexed: 06/03/2023]
Abstract
BACKGROUND Focused echocardiographic examinations performed by intensivists and emergency room physicians can be a valuable tool for diagnosing and managing the hemodynamic status of critically ill children. The aim of this study was to evaluate the learning curve achieved using a theoretical and practical training program designed to enable pediatric intensivists and emergency physicians to conduct targeted echocardiograms. METHODS Theoretical and practical training sessions were conducted with 16 pediatric intensivist/emergency room physicians. The program included qualitative analyses of the left ventricular (LV) and right ventricular (RV) functions, evaluation of pericardial effusion/cardiac tamponade and valvular regurgitation and measurements of the distensibility index of the inferior vena cava (dIVC), ejection fraction (EF) and cardiac index (CI). The practical training sessions were conducted in the intensive care unit; each student performed 24 echocardiograms. The students in training were evaluated in a practical manner, and the results were compared with the corresponding examinations performed by experienced echocardiographers. The evaluations occurred after 8, 16 and 24 practical examinations. RESULTS The concordance rates between the students and echocardiographers in the subjective analysis of the LV function were 81.3% at the first evaluation, 96.9% at the second evaluation and 100% at the third evaluation (p < 0.001). For the dIVC, we observed a concordance of 46.7% at the first evaluation, 90.3% at the second evaluation and 87.5% at the third evaluation (p = 0.004). The means of the differences between the students' and echocardiographers' measurements of the EF and CI were 7% and 0.56 L/min/m2, respectively, after the third stage of training. CONCLUSIONS The proposed training was demonstrated to be sufficient for enabling pediatric physicians to analyze subjective LV function and to measure dIVC, EF and CI. This training course should facilitate the design of other echocardiography training courses that could be implemented in medical residency programs to improve these physicians' technical skills and the care of critically ill patients.
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Affiliation(s)
- Heloisa A Gaspar
- Pediatric Intensive Care - Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina, São Paulo University, Rua do Carreiro de Pedra 111 apto 152C, Jd. Caravelas, CEP 04728-020 São Paulo, Brazil
| | - Samira S Morhy
- Radiology Department - Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina, São Paulo University, São Paulo, Brazil
| | - Alessandro C Lianza
- Radiology Department - Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina, São Paulo University, São Paulo, Brazil
| | - Werther B de Carvalho
- Pediatric Intensive Care - Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina, São Paulo University, Rua do Carreiro de Pedra 111 apto 152C, Jd. Caravelas, CEP 04728-020 São Paulo, Brazil
| | - Jose L Andrade
- Radiology Department - Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina, São Paulo University, São Paulo, Brazil
| | - Rogério R do Prado
- Department of Statistics, Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina, São Paulo University, São Paulo, Brazil
| | - Cláudio Schvartsman
- Emergency Medicine Department, Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina, São Paulo University, São Paulo, Brazil
| | - Artur F Delgado
- Pediatric Intensive Care - Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina, São Paulo University, Rua do Carreiro de Pedra 111 apto 152C, Jd. Caravelas, CEP 04728-020 São Paulo, Brazil
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Lampin ME, Rousseaux J, Botte A, Sadik A, Cremer R, Leclerc F. Noradrenaline use for septic shock in children: doses, routes of administration and complications. Acta Paediatr 2012; 101:e426-30. [PMID: 22568565 DOI: 10.1111/j.1651-2227.2012.02725.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM To report our 10 year experience with noradrenaline use in children with septic shock focusing on doses, routes of administration and complications. METHODS Retrospective single-centre review of children with septic shock who received noradrenaline between 2000 and 2010. RESULTS We identified 144 children with septic shock treated with noradrenaline, in 22% as the first-line drug. The median volume resuscitation before vasoactive agent administration was 50 mL/kg interquartile range [IQR: 30-70]. Mean doses of noradrenaline ranged from 0.5 ± 0.4 μg/kg per min (starting dose) to 2.5 ± 2.2 μg/kg per min (maximum dose). Noradrenaline was administered via peripheral venous access or intra-osseous route in 19% of cases for a median duration of 3 h [IQR: 2-4] without any adverse effects. The use of noradrenaline increased over the study period. Mortality rate was 45% with a significant decrease over the study period. Adverse effects included arrhythmia in two children and hypertension in eight children. None of these arrhythmias required treatment and hypertension resolved with the noradrenaline dose reduction. CONCLUSION Higher doses of noradrenaline than those suggested in the literature may be necessary to reverse hypotension and hypoperfusion. The use of noradrenaline through peripheral venous access or intra-osseous route was safe, without any adverse effects.
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Affiliation(s)
- M E Lampin
- PICU, University hospital of Lille, France
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LI ZHEN, ZHAO GUODONG, ZHOU GUOBIN, WANG YAN, WANG QING, JI JINQUAN, WANG ZHIPENG. Inhibition of S100A9 expression by propofol in monocytes of rats with endotoxemia. Mol Med Rep 2012; 6:657-61. [DOI: 10.3892/mmr.2012.957] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2012] [Accepted: 05/23/2012] [Indexed: 11/06/2022] Open
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Tang J, Chen X, Tu W, Guo Y, Zhao Z, Xue Q, Lin C, Xiao J, Sun X, Tao T, Gu M, Liu Y. Propofol inhibits the activation of p38 through up-regulating the expression of annexin A1 to exert its anti-inflammation effect. PLoS One 2011; 6:e27890. [PMID: 22164217 PMCID: PMC3229486 DOI: 10.1371/journal.pone.0027890] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2011] [Accepted: 10/27/2011] [Indexed: 11/30/2022] Open
Abstract
Inflammatory response is a kind of nonspecific immune response, with the central link of vascular response, which is mainly manifested by changes in neutrophils and vascular endothelial cells. In recent years, the in vivo and in vitro role of intravenous anesthetic propofol in inhibiting inflammatory response has been attracting more and more attention, but the anti-inflammatory mechanisms of propofol for mononuclear cells still remain undefined. In this study, proteomics analysis was applied to investigate protein expression profile changes in serum mononuclear cells following intervention of rats with endotoxemia using propofol. After two-dimensional electrophoresis and mass spectrometric identification, it has been found that the protein Annexin A1 was up-regulated in the propofol intervention group. Annexin A1 is a glucocorticoid-dependent anti-inflammatory protein. After detection using ELISA and Western blot assays, it has also been found that propofol can not only promote the expression of Annexin A1, but also inhibit the phosphorylation level of p38 and release of inflammatory factors (IL-1β, IL-6 and TNF-α) in rats with endotoxemia. In order to further determine the role of up-regulated expression of Annexin A1 in anti-inflammation of propofol, this gene was silenced in vitro in human THP-1 cells, to detect the phosphorylation status of p38 and release of inflammatory factors. The results show that Annexin A1 can negatively regulate phosphorylation of p38 and release of IL-1β, IL-6 and TNF-α in THP-1 cells following propofol intervention and lipopolysaccharide (LPS) stimulation. Our results clearly indicate that propofol can up-regulate Annexin A1 to inhibit the phosphorylation level of p38 and release of IL-1β, IL-6 and TNF-α, so as to inhibit inflammatory response. Therefore, it can be speculated that Annexin A1 might be the key signaling protein in the in vivo and in vitro anti-inflammatory mechanisms of propofol.
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Affiliation(s)
- Jing Tang
- Department of Anesthesia, Nanfang Hospital, Southern Medical University, Guangzhou, People's Republic of China
| | - Xi Chen
- Department of Anesthesia, Guangzhou General Hospital of Guangzhou Military Command, Guangzhou, People's Republic of China
| | - Weifeng Tu
- Department of Anesthesia, Guangzhou General Hospital of Guangzhou Military Command, Guangzhou, People's Republic of China
| | - Yuanbo Guo
- Department of Anesthesia, Nanfang Hospital, Southern Medical University, Guangzhou, People's Republic of China
| | - Zhenlong Zhao
- Department of Anesthesia, Nanfang Hospital, Southern Medical University, Guangzhou, People's Republic of China
| | - Qiong Xue
- Department of Anesthesia, Nanfang Hospital, Southern Medical University, Guangzhou, People's Republic of China
| | - Chunshui Lin
- Department of Anesthesia, Nanfang Hospital, Southern Medical University, Guangzhou, People's Republic of China
| | - Jinfang Xiao
- Department of Anesthesia, Nanfang Hospital, Southern Medical University, Guangzhou, People's Republic of China
| | - Xuegang Sun
- The Key Laboratory of Molecular Biology, State Administration of Traditional Chinese Medicine, School of Traditional Chinese Medicine, Southern Medical University, Guangzhou, People's Republic of China
| | - Tao Tao
- Department of Anesthesia, Nanfang Hospital, Southern Medical University, Guangzhou, People's Republic of China
- * E-mail: (MG); (TT); (YL)
| | - Miaoning Gu
- Department of Anesthesia, Nanfang Hospital, Southern Medical University, Guangzhou, People's Republic of China
- * E-mail: (MG); (TT); (YL)
| | - Youtan Liu
- Department of Anesthesia, Shenzhen Hospital, The University of Hong Kong, Shenzhen, People's Republic of China
- * E-mail: (MG); (TT); (YL)
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Kaeothip S, Paranjape G, Terrill SE, Bongat AFG, Udan MLD, Kamkhachorn T, Johnson HL, Nichols MR, Demchenko AV. Development of LPS antagonistic therapeutics: synthesis and evaluation of glucopyranoside-spacer-amino acid motifs. RSC Adv 2011. [DOI: 10.1039/c1ra00145k] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Abstract
Neonatal septic shock is a devastating condition associated with high morbidity and mortality. Definitions for the sepsis continuum and treatment algorithms specific for premature neonates are needed to improve studies of septic shock and assess benefit from clinical interventions. Unique features of the immature immune system and pathophysiologic responses to sepsis, particularly those of extremely preterm infants, necessitate that clinical trials consider them as a separate group. Keen clinical suspicion and knowledge of risk factors will help to identify those neonates at greatest risk for development of septic shock. Genomic and proteomic approaches, particularly those that use very small sample volumes, will increase our understanding of the pathophysiology and direct the development of novel agents for prevention and treatment of severe sepsis and shock in the neonate. Although at present antimicrobial therapy and supportive care remain the foundation of treatment, in the future immunomodulatory agents are likely to improve outcomes for this vulnerable population.
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Luce WA, Hoffman TM, Bauer JA. Bench-to-bedside review: Developmental influences on the mechanisms, treatment and outcomes of cardiovascular dysfunction in neonatal versus adult sepsis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2008; 11:228. [PMID: 17903309 PMCID: PMC2556733 DOI: 10.1186/cc6091] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Sepsis is a significant cause of morbidity and mortality in neonates and adults, and the mortality rate doubles in patients who develop cardiovascular dysfunction and septic shock. Sepsis is especially devastating in the neonatal population, as it is one of the leading causes of death for hospitalized infants. In the neonate, there are multiple developmental alterations in both the response to pathogens and the response to treatment that distinguish this age group from adults. Differences in innate immunity and cytokine response may predispose neonates to the harmful effects of pro-inflammatory cytokines and oxidative stress, leading to severe organ dysfunction and sequelae during infection and inflammation. Underlying differences in cardiovascular anatomy, function and response to treatment may further alter the neonate's response to pathogen exposure. Unlike adults, little is known about the cardiovascular response to sepsis in the neonate. In addition, recent research has demonstrated that the mechanisms, inflammatory response, response to treatment and outcome of neonatal sepsis vary not only from that of adults, but vary among neonates based on gestational age. The goal of the present article is to review key pathophysiologic aspects of sepsis-related cardiovascular dysfunction, with an emphasis on defining known differences between adult and neonatal populations. Investigations of these relationships may ultimately lead to 'neonate-specific' therapeutic strategies for this devastating and costly medical problem.
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Affiliation(s)
- Wendy A Luce
- Division of Neonatology, Center for Cardiovascular Medicine, Columbus Children's Research Institute, Columbus Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA
| | - Timothy M Hoffman
- Division of Cardiology and Cardiac Critical Care, Center for Cardiovascular Medicine, Columbus Children's Research Institute, Columbus Children's Hospital, Columbus, OH 43205, USA
| | - John Anthony Bauer
- Division of Neonatology, Center for Cardiovascular Medicine, Columbus Children's Research Institute, Columbus Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA
- Division of Cardiology and Cardiac Critical Care, Center for Cardiovascular Medicine, Columbus Children's Research Institute, Columbus Children's Hospital, Columbus, OH 43205, USA
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Monteverde E, Neira P, Farías J. Uso de levosimendan en el shock séptico. An Pediatr (Barc) 2008; 68:529-30. [DOI: 10.1157/13120058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Zuppa AF, Nadkarni VM. Recent developments in the pharmacologic approach to pediatric critical care. Curr Opin Anaesthesiol 2007; 17:223-8. [PMID: 17021555 DOI: 10.1097/00001503-200406000-00005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW There is new information supporting a resurgence of targeted use of older medications. These therapies include hydrocortisone and vasopressin. In addition to these older drugs, newer drugs, drotrecogin alpha (activated protein C) and activated factor VII concentrate (NovoSeven), have been used and may improve outcome in the treatment of critically ill patients. This review summarizes the recent experience of these agents in the adult and pediatric critically ill populations. RECENT FINDINGS Preliminary findings are encouraging in selected septic children and adults for human recombinant activated protein C and protein C concentrate. Plasma vasopressin levels in pediatric septic shock and their importance have not yet been adequately studied. Recent evidence supports physiologic replacement of corticosteroids in specific adult populations. Further investigations are warranted to establish the role of activated factor VIIa in the treatment of critically ill children. SUMMARY The limited experience of protein C manipulation in critically ill septic pediatric patients makes it difficult to define its role in their care. Although it has been associated with improved outcomes, its risk profile warrants judicious use. Further prospective pediatric clinical trials are needed to define the role of vasopressin in the treatment of pediatric shock and cardiac arrest. The role of corticosteroids in the treatment of septic shock in adults and children continues to be debated. Activated factor VIIa administration to adult and pediatric patients without primary bleeding disorders has been increasing. Further investigations are warranted to establish the role of activated factor VIIa in the treatment of critically ill children.
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Affiliation(s)
- Athena F Zuppa
- Department of Anesthesia and Critical Care, Division of Critical Care, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104, USA.
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Massé L, Antonacci M. Low cardiac output syndrome: identification and management. Crit Care Nurs Clin North Am 2006; 17:375-83, x. [PMID: 16344207 DOI: 10.1016/j.ccell.2005.07.005] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Low cardiac output syndrome (LCOS) is a clinical condition that is caused by a transient decrease in systemic perfusion secondary to myocardial dysfunction. The outcome is an imbalance between oxygen delivery and oxygen consumption at the cellular level which leads to metabolic acidosis. Although LCOS is observed most commonly in patients after cardiac surgery, it may present in various disease processes resulting in cardiac dysfunction. This article provides an overview of the determinants involved in oxygen transport, the physiologic factors influencing cardiovascular function, the assessment of hemodynamic variables, the etiology of LCOS, and management strategies, including a brief review of some pharmacologic agents that are used in the treatment of low cardiac output.
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Affiliation(s)
- Linda Massé
- Pediatric Intensive Care Unit, Montreal Children's Hospital, McGill University Centre, 2300 Tupper Street, Room F-240, Montreal, Quebec, H3H 1P3, Canada.
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Chen RM, Chen TG, Chen TL, Lin LL, Chang CC, Chang HC, Wu CH. Anti-Inflammatory and Antioxidative Effects of Propofol on Lipopolysaccharide-Activated Macrophages. Ann N Y Acad Sci 2006; 1042:262-71. [PMID: 15965071 DOI: 10.1196/annals.1338.030] [Citation(s) in RCA: 104] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Sepsis is a serious and life-threatening syndrome that often occurs in intensive care unit (ICU) patients. During sepsis, inflammatory cytokines and nitric oxide (NO) can be overproduced, causing tissue and cell injury. Propofol is an intravenous agent used for sedation of ICU patients. Our previous study showed that propofol has immunosuppressive effects on macrophage functions. This study was designed to evaluate the anti-inflammatory and antioxidative effects of propofol on the biosyntheses of tumor necrosis factor alpha (TNF-alpha), interleukin 1beta (IL-1beta), IL-6, and NO in lipopolysaccharide (LPS)- activated macrophages. Exposure to a therapeutic concentration of propofol (50 microM), LPS (1 ng/mL), or a combination of these two drugs for 1, 6, and 24 h was not cytotoxic to the macrophages. ELISA revealed that LPS increased macrophage TNF-alpha, IL-1beta, and IL-6 protein levels in a time-dependent manner, whereas propofol significantly reduced the levels of LPS-enhanced TNF-alpha, IL-1beta, and IL-6 proteins. Data from RT-PCR showed that LPS induced TNF-alpha, IL-1beta, and IL-6 mRNA, but propofol inhibited these effects. LPS also increased NO production and inducible nitric oxide synthase (iNOS) expression in macrophages. Exposure of macrophages to propofol significantly inhibited the LPS-induced NO biosynthesis. The present study shows that propofol, at a therapeutic concentration, has anti-inflammatory and antioxidative effects on the biosyntheses of TNF-alpha, IL-1beta, IL-6, and NO in LPS-activated macro-phages and that the suppressive effects are exerted at the pretranslational level.
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Affiliation(s)
- Ruei-Ming Chen
- Graduate Institute of Medical Sciences, College of Medicine, Taipei Medical University, No. 250, Wu-Hsing St., Taipei 110, Taiwan.
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Abstract
A significant percentage of pediatric patients admitted to an ICU have an infectious disease process. Many infants and children go on to develop sepsis, a major cause of death in the intensive care unit. Caring for these children presents a collaborative challenge because of the multifactorial etiology and the complicated pathophysiology. This article focuses on the specific implications of sepsis for infants and children.
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Affiliation(s)
- Patricia A Moloney-Harmon
- Children's Services, Sinai Hospital of Baltimore, 2401 W. Belvedere Avenue, Baltimore MD 21215, USA.
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Rosenthal D, Chrisant MRK, Edens E, Mahony L, Canter C, Colan S, Dubin A, Lamour J, Ross R, Shaddy R, Addonizio L, Beerman L, Berger S, Bernstein D, Blume E, Boucek M, Checchia P, Dipchand A, Drummond-Webb J, Fricker J, Friedman R, Hallowell S, Jaquiss R, Mital S, Pahl E, Pearce FB, Pearce B, Rhodes L, Rotondo K, Rusconi P, Scheel J, Pal Singh T, Towbin J. International Society for Heart and Lung Transplantation: Practice guidelines for management of heart failure in children. J Heart Lung Transplant 2005; 23:1313-33. [PMID: 15607659 DOI: 10.1016/j.healun.2004.03.018] [Citation(s) in RCA: 178] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- David Rosenthal
- International Society for Heart and Lung Transplantation, Addison, Texas.
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Minneci PC, Deans KJ, Banks SM, Costello R, Csako G, Eichacker PQ, Danner RL, Natanson C, Solomon SB. Differing effects of epinephrine, norepinephrine, and vasopressin on survival in a canine model of septic shock. Am J Physiol Heart Circ Physiol 2004; 287:H2545-54. [PMID: 15319205 DOI: 10.1152/ajpheart.00450.2004] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
During sepsis, limited data on the survival effects of vasopressors are available to guide therapy. Therefore, we compared the effects of three vasopressors on survival in a canine septic shock model. Seventy-eight awake dogs infected with differing doses of intraperitoneal Escherichia coli to produce increasing mortality were randomized to receive epinephrine (0.2, 0.8, or 2.0 μg·kg−1·min−1), norepinephrine (0.2, 1.0, or 2.0 μg·kg−1·min−1), vasopressin (0.01 or 0.04 U/min), or placebo in addition to antibiotics and fluids. Serial hemodynamic and biochemical variables were measured. Increasing doses of bacteria caused progressively greater decreases in survival ( P < 0.06), mean arterial pressure (MAP) ( P < 0.05), cardiac index (CI) ( P < 0.02), and ejection fraction (EF) ( P = 0.02). The effects of epinephrine on survival were significantly different from those of norepinephrine and vasopressin ( P = 0.03). Epinephrine had a harmful effect on survival that was significantly related to drug dose ( P = 0.02) but not bacterial dose. Norepinephrine and vasopressin had beneficial effects on survival that were similar at all drug and bacteria doses. Compared with concurrent infected controls, epinephrine caused greater decreases in CI, EF, and pH, and greater increases in systemic vascular resistance and serum creatinine than norepinephrine and vasopressin. These epinephrine-induced changes were significantly related to the dose of epinephrine administered. In this study, the effects of vasopressors were independent of severity of infection but dependent on the type and dose of vasopressor used. Epinephrine adversely affected organ function, systemic perfusion, and survival compared with norepinephrine and vasopressin. In the ranges studied, norepinephrine and vasopressin have more favorable risk-benefit profiles than epinephrine during sepsis.
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Affiliation(s)
- Peter C Minneci
- Critical Care Medicine Department, National Institutes of Health, 10 Center Dr., Bldg 10, Rm 7D43, Bethesda, MD 20892, USA.
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Pershad J, Myers S, Plouman C, Rosson C, Elam K, Wan J, Chin T. Bedside limited echocardiography by the emergency physician is accurate during evaluation of the critically ill patient. Pediatrics 2004; 114:e667-71. [PMID: 15545620 DOI: 10.1542/peds.2004-0881] [Citation(s) in RCA: 169] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Echocardiography can be a rapid, noninvasive, objective tool in the assessment of ventricular function and preload during resuscitation of a critically ill or injured child. We sought to determine the accuracy of bedside limited echocardiography by the emergency physician (BLEEP) in estimation of (1) left ventricular function (LVF) and (2) inferior vena cava (IVC) volume, as an indirect measure of preload. METHODS We conducted a prospective observational study of a convenience sample of patients who were admitted to our intensive care unit. All patients underwent BLEEP followed by an independent formal echocardiogram by an experienced pediatric echocardiography provider (PEP). IVC volume was assessed by measurement of the maximal diameter of the IVC. LVF was determined by calculating shortening fraction (SF) using M-mode measurements on the parasternal short-axis view at the level of the papillary muscle. An independent blinded pediatric cardiologist reviewed all images for accuracy and quality. Estimates of SF obtained on the BLEEP examination were compared with those obtained by the PEP. RESULTS Thirty-one patients were enrolled. The mean age was 5.1 years (range: 23 days-16 years); 48.4% (15 of 31) were girls; 58.1% (18 of 31) were on mechanical ventilatory support at the time of their study. There was good agreement between the emergency physician (EP) and the PEP for estimation of SF (r = 0.78). The mean difference in the estimate of SF between the providers was 4.4% (95% confidence interval: 1.6%-7.2%). This difference in estimate of SF was statistically significant. Similarly, there was good agreement between the EP and the PEP for estimation of IVC volume (r = 0.8). The mean difference in the estimate of IVC diameter by the PEP and the EP was 0.068 mm (95% confidence interval: -0.16 to 0.025 mm). This difference was not statistically significant. CONCLUSIONS Our study suggests that PEP sonographers are capable of obtaining images that permit accurate assessment of LVF and IVC volume. BLEEP can be performed with focused training and oversight by a pediatric cardiologist.
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Affiliation(s)
- Jay Pershad
- Division of Emergency Medicine, Department of Pediatrics, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA.
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Gilmore B, Noe HN, Chin T, Pershad J. Posterior urethral valves presenting as abdominal distension and undifferentiated shock in a neonate: The role of screening emergency physician-directed bedside ultrasound. J Emerg Med 2004; 27:265-9. [PMID: 15388214 DOI: 10.1016/j.jemermed.2004.04.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2003] [Revised: 03/31/2004] [Accepted: 04/22/2004] [Indexed: 10/26/2022]
Abstract
We present a case of shock in a 7-week-old neonate with obstructive uropathy secondary to posterior urethral valves (PUV). The antenatal ultrasound and the 2-week maintenance visit were unremarkable. A screening emergency physician directed bedside ultrasound (SEPUS) served to rapidly establish the diagnosis, initiate appropriate management, and facilitate early relief of urinary obstruction. We discuss the potential role of SEPUS in a critically ill neonate and briefly review the management of PUV.
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Affiliation(s)
- Barry Gilmore
- Division of Critical Care & Emergency Services, LeBonheur Children's Medical Center, Memphis, Tennessee, USA
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Abstract
Septic shock causes more deaths in children than cancer. However, studies have shown that mortality can be significantly reduced by adhering to the American College of Critical Care Medicine/Pediatric Advanced Life Support guidelines. This article reviews the definitions, pathophysiology, and emergency management of children with septic shock, including the controversial role of steroids.
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Affiliation(s)
- Stefan P Maar
- Emergency Department, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
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Wu CH, Chen TL, Chen TG, Ho WP, Chiu WT, Chen RM. Nitric oxide modulates pro- and anti-inflammatory cytokines in lipopolysaccharide-activated macrophages. ACTA ACUST UNITED AC 2003; 55:540-5. [PMID: 14501900 DOI: 10.1097/01.ta.0000033496.62796.3b] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Sepsis is a serious and life-threatening syndrome that occurs in intensive care unit patients. Lipopolysaccharide (LPS) has been implicated as one of major causes of sepsis. Nitric oxide (NO) and cytokines are involved in sepsis-induced inflammatory responses. This study is aimed at evaluating the effects of NO on the modulation of pro- and anti-inflammatory cytokines in LPS-activated macrophages and its possible mechanism. METHODS N-Monomethyl arginine (NMMA), an inhibitor of NO synthase, was used in this study to suppress NO production. Mouse macrophage-like Raw 264.7 cells were exposed to LPS, NMMA, or a combination of NMMA and LPS. Cell viability was determined by the colorimetric 3-(4,5-dimethylthiazol-2-yl)-2,5-di-phenyltetrazolium bromide assay. The amounts of nitrite, an oxidative product of NO, in the culture medium were quantified according to the Griess reaction method. Enzyme-linked immunosorbent assay and reverse-transcriptase polymerase chain reaction were carried out to determine the expression of tumor necrosis factor (TNF)-alpha, interleukin (IL)-1 beta, and IL-10 in macrophages. RESULTS Exposure of macrophages to LPS, NMMA, and a combination of NMMA and LPS for 24 hours did not affect cell viability. LPS significantly increased the amounts of nitrite in macrophages (p < 0.01). Treatment with NMMA decreased LPS-enhanced nitrite (p < 0.01) in a concentration-dependent manner. Analyses of enzyme-linked immunosorbent assays and reverse-transcriptase polymerase chain reaction revealed that LPS significantly induced TNF-alpha, IL-1 beta, and IL-10 proteins and mRNA (p < 0.01). A combined treatment with NMMA and LPS significantly blocked LPS-induced TNF-alpha and IL-1 beta (p < 0.01), but synergistically enhanced LPS-induced IL-10 (p < 0.05) protein and RNA. CONCLUSION This study has shown that NO suppression can inhibit LPS-induced TNF-alpha and IL-1 beta but enhance IL-10, and the modulation occurs at a pretranslational level.
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Affiliation(s)
- Chih-Hsiung Wu
- Department of Surgery, Taipei Medical University Hospital, Taiwan
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Arnal LE, Stein F. Pediatric septic shock: why has mortality decreased?-the utility of goal-directed therapy. SEMINARS IN PEDIATRIC INFECTIOUS DISEASES 2003; 14:165-72. [PMID: 12881803 DOI: 10.1053/spid.2003.127233] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Mortality from septic shock in children has decreased by 92 percent in the last 36 years. The contributions of goal-directed therapy, intensive care, and other forms of support are responsible for this decrease. A deeper and more specific understanding of innate immunity and the biomolecular processes that operate in septic shock has offered the scientific basis to implement goal-directed therapies. However, therapies that are aimed specifically at manipulating the inflammatory cascade have yet to prove safe and effective.
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Affiliation(s)
- Luisa E Arnal
- Department of Pediatrics, Baylor College of Medicine Residency Program and the Section of Pediatric Critical Care, Baylor College of Medicine and Texas Children's Hospital, Houston, TX 77030, USA
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