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Dimitriadis K, Damianaki A, Bletsa E, Pyrpyris N, Tsioufis P, Theofilis P, Beneki E, Tatakis F, Kasiakogias A, Oikonomou E, Petras D, Siasos G, Aggeli K, Tsioufis K. Renal Congestion in Heart Failure: Insights in Novel Diagnostic Modalities. Cardiol Rev 2024:00045415-990000000-00224. [PMID: 38427026 DOI: 10.1097/crd.0000000000000673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
Heart failure is increasingly prevalent and is estimated to increase its burden in the following years. A well-reported comorbidity of heart failure is renal dysfunction, where predominantly changes in the patient's volume status, tubular necrosis or other mechanical and neurohormonal mechanisms seem to drive this impairment. Currently, there are established biomarkers evaluating the patient's clinical status solely regarding the cardiovascular or renal system. However, as the coexistence of heart and renal failure is common and related to increased mortality and hospitalization for heart failure, it is of major importance to establish novel diagnostic techniques, which could identify patients with or at risk for cardiorenal syndrome and assist in selecting the appropriate management for these patients. Such techniques include biomarkers and imaging. In regards to biomarkers, several peptides and miRNAs indicative of renal or tubular dysfunction seem to properly identify patients with cardiorenal syndrome early on in the course of the disease, while changes in their serum levels can also be helpful in identifying response to diuretic treatment. Current and novel imaging techniques can also identify heart failure patients with early renal insufficiency and assess the volume status and the effect of treatment of each patient. Furthermore, by assessing the renal morphology, these techniques could also help identify those at risk of kidney impairment. This review aims to present all relevant clinical and trial data available in order to provide an up-to-date summary of the modalities available to properly assess cardiorenal syndrome.
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Affiliation(s)
- Kyriakos Dimitriadis
- From the First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | | | - Evanthia Bletsa
- 3rd Department of Cardiology, Sotiria Hospital, University of Athens, Athens, Greece
| | - Nikolaos Pyrpyris
- From the First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Panagiotis Tsioufis
- From the First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Panagiotis Theofilis
- From the First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Eirini Beneki
- From the First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Fotis Tatakis
- From the First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Alexandros Kasiakogias
- From the First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Evangelos Oikonomou
- 3rd Department of Cardiology, Sotiria Hospital, University of Athens, Athens, Greece
| | | | - Gerasimos Siasos
- 3rd Department of Cardiology, Sotiria Hospital, University of Athens, Athens, Greece
| | - Konstantina Aggeli
- From the First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Konstantinos Tsioufis
- From the First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
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Peng JC, Wu Y, Xing SP, Zhu ML, Gao Y, Li W. Development and validation of a nomogram to predict the risk of renal replacement therapy among acute kidney injury patients in intensive care unit. Clin Exp Nephrol 2023; 27:951-960. [PMID: 37498349 PMCID: PMC10581925 DOI: 10.1007/s10157-023-02383-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 07/11/2023] [Indexed: 07/28/2023]
Abstract
BACKGROUND There are no universally accepted indications to initiate renal replacement therapy (RRT) among patients with acute kidney injury (AKI). This study aimed to develop a nomogram to predict the risk of RRT among AKI patients in intensive care unit (ICU). METHODS In this retrospective cohort study, we extracted AKI patients from Medical Information Mart for Intensive Care III (MIMIC-III) database. Patients were randomly divided into a training cohort (70%) and a validation cohort (30%). Multivariable logistic regression based on Akaike information criterion was used to establish the nomogram. The discrimination and calibration of the nomogram were evaluated by Harrell's concordance index (C-index) and Hosmer-Lemeshow (HL) test. Decision curve analysis (DCA) was performed to evaluate clinical application. RESULTS A total of 7413 critically ill patients with AKI were finally enrolled. 514 (6.9%) patients received RRT after ICU admission. 5194 (70%) patients were in the training cohort and 2219 (30%) patients were in the validation cohort. Nine variables, namely, age, hemoglobin, creatinine, blood urea nitrogen and lactate at AKI detection, comorbidity of congestive heart failure, AKI stage, and vasopressor use were included in the nomogram. The predictive model demonstrated satisfying discrimination and calibration with C-index of 0.938 (95% CI, 0.927-0.949; HL test, P = 0.430) in training set and 0.935 (95% CI, 0.919-0.951; HL test, P = 0.392) in validation set. DCA showed a positive net benefit of our nomogram. CONCLUSION The nomogram developed in this study was highly accurate for RRT prediction with potential application value.
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Affiliation(s)
- Jiang-Chen Peng
- Department of Critical Care, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, 160 Pujian Road, Shanghai, 200127, China
| | - Yan Wu
- Department of Critical Care, Shanghai Baoshan Luodian Hospital, 121 Luoxi Road, Baoshan District, Shanghai, 201908, China
| | - Shun-Peng Xing
- Department of Critical Care, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, 160 Pujian Road, Shanghai, 200127, China
| | - Ming-Li Zhu
- Department of Critical Care, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, 160 Pujian Road, Shanghai, 200127, China
| | - Yuan Gao
- Department of Critical Care, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, 160 Pujian Road, Shanghai, 200127, China
| | - Wen Li
- Department of Critical Care, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, 160 Pujian Road, Shanghai, 200127, China.
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Heringlake M, Alvarez J, Bettex D, Bouchez S, Fruhwald S, Girardis M, Grossini E, Guarracino F, Herpain A, Toller W, Tritapepe L, Pollesello P. An update on levosimendan in acute cardiac care: applications and recommendations for optimal efficacy and safety. Expert Rev Cardiovasc Ther 2021; 19:325-335. [PMID: 33739204 DOI: 10.1080/14779072.2021.1905520] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Introduction: In the 20 years since its introduction to the palette of intravenous hemodynamic therapies, the inodilator levosimendan has established itself as a valuable asset for the management of acute decompensated heart failure. Its pharmacology is notable for delivering inotropy via calcium sensitization without an increase in myocardial oxygen consumption.Areas covered: Experience with levosimendan has led to its applications expanding into perioperative hemodynamic support and various critical care settings, as well as an array of situations associated with acutely decompensated heart failure, such as right ventricular failure, cardiogenic shock with multi-organ dysfunction, and cardio-renal syndrome. Evidence suggests that levosimendan may be preferable to milrinone for patients in cardiogenic shock after cardiac surgery or for weaning from extracorporeal life support and may be superior to dobutamine in terms of short-term survival, especially in patients on beta-blockers. Positive effects on kidney function have been noted, further differentiating levosimendan from catecholamines and phosphodiesterase inhibitors.Expert opinion:Levosimendan can be a valuable resource in the treatment of acute cardiac dysfunction, especially in the presence of beta-blockers or ischemic cardiomyopathy. When attention is given to avoiding or correcting hypovolemia and hypokalemia, an early use of the drug in the treatment algorithm is preferred.
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Affiliation(s)
- Matthias Heringlake
- Klinik Für Anästhesie Und Intensivmedizin, Herz- Und Diabeteszentrum Mecklenburg Vorpommern, Karlsburg, Germany
| | - Julian Alvarez
- Department of Anesthesia and Surgical ICU, University of Santiago De Compostela, Santiago De Compostela, Spain
| | - Dominique Bettex
- Institute for Anaesthesiology, University Zürich and University Hospital Zürich, Zürich, Switzerland
| | - Stefaan Bouchez
- Department of Anesthesiology, University Hospital, Ghent, Belgium
| | - Sonja Fruhwald
- Department of Anaesthesiology and Intensive Care Medicine, Division of Anaesthesiology for Cardiovascular Surgery and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Massimo Girardis
- Struttura Complessa Di Anestesia 1, Policlinico Di Modena, Modena, Italy
| | - Elena Grossini
- Laboratory of Physiology, Department of Translational Medicine, Università Piemonte Orientale, Novara, Italy
| | - Fabio Guarracino
- Dipartimento Di Anestesia E Rianimazione, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Antoine Herpain
- Department of Intensive Care, Erasme University Hospital, Université Libre De Bruxelles, Brussels, Belgium
| | - Wolfgang Toller
- Department of Anaesthesiology and Intensive Care Medicine, Division of Anaesthesiology for Cardiovascular Surgery and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Luigi Tritapepe
- UOC Anestesia E Rianimazione, Azienda Ospedaliera San Camillo-Forlanini, Rome, Italy; and
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Guarracino F, Habicher M, Treskatsch S, Sander M, Szekely A, Paternoster G, Salvi L, Lysenko L, Gaudard P, Giannakopoulos P, Kilger E, Rompola A, Häberle H, Knotzer J, Schirmer U, Fellahi JL, Hajjar LA, Kettner S, Groesdonk HV, Heringlake M. Vasopressor Therapy in Cardiac Surgery-An Experts' Consensus Statement. J Cardiothorac Vasc Anesth 2020; 35:1018-1029. [PMID: 33334651 DOI: 10.1053/j.jvca.2020.11.032] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Revised: 11/09/2020] [Accepted: 11/13/2020] [Indexed: 12/17/2022]
Abstract
Hemodynamic conditions with reduced systemic vascular resistance commonly are observed in patients undergoing cardiac surgery and may range from moderate reductions in vascular tone, as a side effect of general anesthetics, to a profound vasodilatory syndrome, often referred to as vasoplegic shock. Therapy with vasopressors is an important pillar in the treatment of these conditions. There is limited guidance on the appropriate choice of vasopressors to restore and optimize systemic vascular tone in patients undergoing cardiac surgery. A panel of experts in the field convened to develop statements and evidence-based recommendations on clinically relevant questions on the use of vasopressors in cardiac surgical patients, using a critical appraisal of the literature following the GRADE system and a modified Delphi process. The authors unanimously and strongly recommend the use of norepinephrine and/or vasopressin for restoration and maintenance of systemic perfusion pressure in cardiac surgical patients; despite that, the authors cannot recommend either of these drugs with respect to the risk of ischemic complications. The authors unanimously and strongly recommend against using dopamine for treating post-cardiac surgery vasoplegic shock and against using methylene blue for purposes other than a rescue therapy. The authors unanimously and weakly recommend that clinicians consider early addition of a second vasopressor (norepinephrine or vasopressin) if adequate vascular tone cannot be restored by a monotherapy with either norepinephrine or vasopressin and to consider using vasopressin as a first-line vasopressor or to add vasopressin to norepinephrine in cardiac surgical patients with pulmonary hypertension or right-sided heart dysfunction.
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Affiliation(s)
- Fabio Guarracino
- Department of Anesthesia and Intensive Care Medicine, University Hospital of Pisa, Pisa, Italy
| | - Marit Habicher
- Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, University Hospital Gieβen, Justus-Liebig University Gieβen, Germany
| | - Sascha Treskatsch
- Department of Anesthesiology and Operative Intensive Care Medicine Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Berlin, Germany; Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany; Berlin Institute of Health, Berlin, Germany
| | - Michael Sander
- Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, University Hospital Gieβen, Justus-Liebig University Gieβen, Germany
| | - Andrea Szekely
- Department of Anesthesia, Semmelweis University Budapest, Budapest, Hungary
| | - Gianluca Paternoster
- Division of Cardiac Resuscitation, Cardiovascular Anesthesia and Intensive Care, San Carlo Hospital, Potenza, Italy
| | - Luca Salvi
- IRCCS Centro Cardiologico Monzino, Milano, Italy
| | - Lidia Lysenko
- Department of Anesthesiology and Intensive Therapy, Wroclaw Medical University, Wroclaw, Poland
| | - Phillipe Gaudard
- Department of Anaesthesiology and Critical Care Medicine Arnaud de Villeneuve, CHU Montpellier, University of Montpellier, PhyMedExp, INSERM, CNRS, Montpellier, France
| | | | - Erich Kilger
- Department of Anesthesiology, Ludwig-Maximilians University of Munich, Munich, Germany
| | - Amalia Rompola
- Department of Cardiac Surgery Intensive Care, Onassis Cardiac Center, Kallithea Athens, Greece
| | - Helene Häberle
- Department of Anesthesiology and Intensive Care Medicine, University of Tübingen, Tübingen, Germany
| | - Johann Knotzer
- Department of Anaesthesiology and Critical Care Medicine, County Hospital Wels, Wels, Austria
| | - Uwe Schirmer
- Institute for Anesthesiology, Heart, and Diabetes Center, Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - Jean-Luc Fellahi
- Department of Anesthesiology and Critical Care, Hôpital Cardiologique Louis Pradel, Lyon, France
| | - Ludhmila Abrahao Hajjar
- Department of Cardiopneumology, Instituto do Coração, Hospital das Clínicas, Sao Paulo, Brazil
| | - Stephan Kettner
- Department of Anesthesiology and Intensive Care, Vienna Hospital Association, Vienna, Austria
| | | | - Matthias Heringlake
- Department of Anesthesiology and Intensive Care, Heart- and Diabetes Center Mecklenburg - Western Pomerania, Karlsburg, Germany.
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Effect of Continuous Epinephrine Infusion on Survival in Critically Ill Patients: A Meta-Analysis of Randomized Trials. Crit Care Med 2020; 48:398-405. [PMID: 31789701 DOI: 10.1097/ccm.0000000000004127] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVES Epinephrine is frequently used as an inotropic and vasopressor agent in critically ill patients requiring hemodynamic support. Data from observational trials suggested that epinephrine use is associated with a worse outcome as compared with other adrenergic and nonadrenergic vasoactive drugs. We performed a systematic review and meta-analysis of randomized controlled trials to investigate the effect of epinephrine administration on outcome of critically ill patients. DATA SOURCES PubMed, EMBASE, and Cochrane central register were searched by two independent investigators up to March 2019. STUDY SELECTION Inclusion criteria were: administration of epinephrine as IV continuous infusion, patients admitted to an ICU or undergoing major surgery, and randomized controlled trials. Studies on epinephrine administration as bolus (e.g., during cardiopulmonary resuscitation), were excluded. The primary outcome was mortality at the longest follow-up available. DATA EXTRACTION Two independent investigators examined and extracted data from eligible trials. DATA SYNTHESIS A total of 5,249 studies were assessed, with a total of 12 studies (1,227 patients) finally included in the meta-analysis. The majority of the trials were performed in the setting of septic shock, and the most frequent comparator was a combination of norepinephrine plus dobutamine. We found no difference in all-cause mortality at the longest follow-up available (197/579 [34.0%] in the epinephrine group vs 219/648 [33.8%] in the control group; risk ratio = 0.95; 95% CI, 0.82-1.10; p = 0.49; I = 0%). No differences in the need for renal replacement therapy, occurrence rate of myocardial ischemia, occurrence rate of arrhythmias, and length of ICU stay were observed. CONCLUSIONS Current randomized evidence showed that continuous IV administration of epinephrine as inotropic/vasopressor agent is not associated with a worse outcome in critically ill patients.
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Ren YS, Li LF, Peng T, Tan YJ, Sun Y, Cheng GL, Zhang GM, Li J. The effect of milrinone on mortality in adult patients who underwent CABG surgery: a systematic review of randomized clinical trials with a meta-analysis and trial sequential analysis. BMC Cardiovasc Disord 2020; 20:328. [PMID: 32640988 PMCID: PMC7346403 DOI: 10.1186/s12872-020-01598-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 06/25/2020] [Indexed: 12/12/2022] Open
Abstract
Background As an inodilator, milrinone is commonly used for patients who undergo coronary artery bypass graft (CABG) surgery because of its effectiveness in decreasing the cardiac index and mitral regurgitation. The aim of this study was to perform a systematic review and meta-analysis of existing studies from the past 20 years to evaluate the impact of milrinone on mortality in patients who undergo CABG surgery. Methods We performed a systematic literature search on the application of milrinone in patients who underwent CABG surgery in studies published between 1997 and 2017 in BioMed Central, PubMed, EMBASE, and the Cochrane Central Register. The included studies evaluated milrinone groups compared to groups receiving either placebo or standard treatment and further compared the systemic administration. Results The network meta-analysis included 723 patients from 16 randomized clinical trials. Overall, there was no significant difference in mortality between the milrinone group and the placebo/standard care group when patients underwent CABG surgery. In addition, 9 trials (with 440 randomized patients), 4 trials (with 212 randomized patients), and 10 trials (with 470 randomized patients) reported that the occurrence of myocardial infarction (MI), myocardial ischemia, and arrhythmia was lower in the milrinone group than in the placebo/standard care group. Between the milrinone treatment and placebo/standard care groups, the occurrence of myocardial infarction, myocardial ischemia, and arrhythmia was significantly different. However, the occurrence of stroke and renal failure, the duration of inotropic support (h), the need for an intra-aortic balloon pump (IABP), and mechanical ventilation (h) between these two groups showed no differences. Conclusions Based on the current results, compared with placebo, milrinone might be unable to decrease mortality in adult CABG surgical patients but can significantly ameliorate the occurrence of MI, myocardial ischemia, and arrhythmia. These results provide evidence for the further clinical application of milrinone and of therapeutic strategies for CABG surgery. However, along with milrinone application in clinical use, sufficient data from randomized clinical trials need to be collected, and the potential benefits and adverse effects should be analyzed and reevaluated.
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Affiliation(s)
- Yu-Shan Ren
- Shandong New Time Pharmaceutical Co, Ltd., Linyi, China.,National Engineering and Technology Research Center of Chirality Pharmaceutica, Lunan Pharmaceutical Group Co, Ltd., Linyi, China.,State Key Laboratory of Generic Manufacture Technology of Chinese Traditional Medicine, Lunan Pharmaceutical Group Co, Ltd., Linyi, China
| | - Lan-Fang Li
- Shandong New Time Pharmaceutical Co, Ltd., Linyi, China.,State Key Laboratory of Generic Manufacture Technology of Chinese Traditional Medicine, Lunan Pharmaceutical Group Co, Ltd., Linyi, China
| | - Tao Peng
- Shandong New Time Pharmaceutical Co, Ltd., Linyi, China.,State Key Laboratory of Generic Manufacture Technology of Chinese Traditional Medicine, Lunan Pharmaceutical Group Co, Ltd., Linyi, China
| | - Yu-Jun Tan
- Shandong New Time Pharmaceutical Co, Ltd., Linyi, China.,National Engineering and Technology Research Center of Chirality Pharmaceutica, Lunan Pharmaceutical Group Co, Ltd., Linyi, China.,State Key Laboratory of Generic Manufacture Technology of Chinese Traditional Medicine, Lunan Pharmaceutical Group Co, Ltd., Linyi, China
| | - Ying Sun
- Shandong New Time Pharmaceutical Co, Ltd., Linyi, China.,State Key Laboratory of Generic Manufacture Technology of Chinese Traditional Medicine, Lunan Pharmaceutical Group Co, Ltd., Linyi, China
| | - Guo-Liang Cheng
- Shandong New Time Pharmaceutical Co, Ltd., Linyi, China.,State Key Laboratory of Generic Manufacture Technology of Chinese Traditional Medicine, Lunan Pharmaceutical Group Co, Ltd., Linyi, China
| | - Gui-Min Zhang
- Shandong New Time Pharmaceutical Co, Ltd., Linyi, China.,National Engineering and Technology Research Center of Chirality Pharmaceutica, Lunan Pharmaceutical Group Co, Ltd., Linyi, China.,State Key Laboratory of Generic Manufacture Technology of Chinese Traditional Medicine, Lunan Pharmaceutical Group Co, Ltd., Linyi, China
| | - Jie Li
- Shandong New Time Pharmaceutical Co, Ltd., Linyi, China. .,National Engineering and Technology Research Center of Chirality Pharmaceutica, Lunan Pharmaceutical Group Co, Ltd., Linyi, China. .,State Key Laboratory of Generic Manufacture Technology of Chinese Traditional Medicine, Lunan Pharmaceutical Group Co, Ltd., Linyi, China.
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7
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Haas A, Schürholz T, Reuter DA. [Perioperative pharmacological circulatory support in daily clinical routine]. Anaesthesist 2020; 69:781-792. [PMID: 32572502 DOI: 10.1007/s00101-020-00803-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Perioperative phases of hypotension are associated with an increase in postoperative complications and organ damage. Whereas some years ago hemodynamic stabilization was primarily carried out by volume supplementation, in recent years the use and dosing of cardiovascular-active substances has significantly increased. But like intravascular volume therapy, also substances with a cardiovascular effect have therapeutic margins, and thus, potential side effects. This review article discusses indications for each cardiovascular-active agent, weighing up advantages and disadvantages. Special attention is paid to the question how to administrate them: central venous catheter vs. peripheral indwelling venous cannula. The authors come to the conclusion that it is not a question of whether it is principally allowed to apply cardiovascular-active drugs via peripheral veins but more importantly, what should be taken into consideration if a peripheral venous access is used. This article provides concise recommendations.
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Affiliation(s)
- A Haas
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsmedizin Rostock, Schillingallee 35, 18057, Rostock, Deutschland
| | - T Schürholz
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsmedizin Rostock, Schillingallee 35, 18057, Rostock, Deutschland
| | - D A Reuter
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsmedizin Rostock, Schillingallee 35, 18057, Rostock, Deutschland.
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Long L, Zhao HT, Shen LM, He C, Ren S, Zhao HL. Hemodynamic effects of inotropic drugs in heart failure: A network meta-analysis of clinical trials. Medicine (Baltimore) 2019; 98:e18144. [PMID: 31764856 PMCID: PMC6882628 DOI: 10.1097/md.0000000000018144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND There is currently no consensus on the appropriate selection of inotropic therapy in ventricular dysfunction. The objective of the study was to detect the effects of different inotropes on the hemodynamics of patients who developed low cardiac output. METHODS PubMed, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched (all updated December 31, 2017). The inclusion criteria were as follows: low cardiac index (CI < 2.5 L/min/m) or New York Heart Association class II-IV, and at least 1 group receiving an inotropic drug compared to another group receiving a different inotropic/placebo treatment. The exclusion criteria were studies published as an abstract only, crossover studies, and studies with a lack of data on the cardiac index. RESULTS A total of 1402 patients from 37 trials were included in the study. Inotropic drugs were shown to increase the cardiac index (0.32, 95%CI:0.25, 0.38), heart rate (7.68, 95%CI:6.36, 9.01), and mean arterial pressure (3.17, 95%CI:1.96, 4.38) than the placebo. Overall, the pooled estimates showed no difference in terms of cardiac index, heart rate, mean arterial pressure, systemic vascular resistance, and mean pulmonary arterial pressure among the groups receiving different inotropes. CONCLUSIONS Our systematic review found that inotrope therapy is not associated with the amelioration of hemodynamics. An accurate evaluation of the benefits and risks, and selection of the correct inotropic agent is required in all clinical settings.
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Affiliation(s)
| | - Hao-tian Zhao
- Department of Ultrasound, Hebei General Hospital, Hebei, China
| | | | - Cong He
- Department of Intensive Care Unit
| | - Shan Ren
- Department of Intensive Care Unit
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Papadakis E, Kanakis M, Kataki A, Spandidos DA. The spectrum of myocardial homeostasis mechanisms in the settings of cardiac surgery procedures (Review). Mol Med Rep 2017; 17:2089-2099. [PMID: 29207125 PMCID: PMC5783448 DOI: 10.3892/mmr.2017.8174] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Accepted: 11/28/2017] [Indexed: 12/13/2022] Open
Abstract
Classic cardiac surgery, determined through the function of cardiopulmonary bypass machine and myocardial cardioplegic arrest, represents the most controlled scenario for cardiomyocyte homeostatic disturbances due to systemic inflammatory response and myocardial reperfusion injury. An increasing number of studies have demonstrated that myocardial cell homeostasis in cardiac surgery procedures is a sequence of molecularly interrelated and overlapping mechanisms in the form of apoptosis, autophagy and necrosis, which are activated by a plethora of induced inflammatory mediators and gene-related signaling pathways. In this study, we outline the molecular mechanisms of the cardiomyocyte adaptive homeostatic process and the associated clinical implications, in the settings of classic cardiac surgery procedures.
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Affiliation(s)
- Emmanuel Papadakis
- Department of Cardiac Surgery, Onassis Cardiac Surgery Center, 17674 Athens, Greece
| | - Meletios Kanakis
- Cardiothoracic Surgery Unit, Great Ormond Street Hospital for Children, WC1N 3JH London, UK
| | - Agapi Kataki
- Propaedeutic Surgery First Department, University of Athens, 11527 Athens, Greece
| | - Demetrios A Spandidos
- Laboratory of Clinical Virology, Medical School, University of Crete, 71003 Heraklion, Crete, Greece
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10
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Koster G, Bekema HJ, Wetterslev J, Gluud C, Keus F, van der Horst ICC. Milrinone for cardiac dysfunction in critically ill adult patients: a systematic review of randomised clinical trials with meta-analysis and trial sequential analysis. Intensive Care Med 2016; 42:1322-35. [PMID: 27448246 PMCID: PMC4992029 DOI: 10.1007/s00134-016-4449-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 07/09/2016] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Milrinone is an inotrope widely used for treatment of cardiac failure. Because previous meta-analyses had methodological flaws, we decided to conduct a systematic review of the effect of milrinone in critically ill adult patients with cardiac dysfunction. METHODS This systematic review was performed according to The Cochrane Handbook for Systematic Reviews of Interventions. Searches were conducted until November 2015. Patients with cardiac dysfunction were included. The primary outcome was serious adverse events (SAE) including mortality at maximum follow-up. The risk of bias was evaluated and trial sequential analyses were conducted. The quality of evidence was assessed by the Grading of Recommendations Assessment, Development and Evaluation criteria. RESULTS A total of 31 randomised clinical trials fulfilled the inclusion criteria, of which 16 provided data for our analyses. All trials were at high risk of bias, and none reported the primary composite outcome SAE. Fourteen trials with 1611 randomised patients reported mortality data at maximum follow-up (RR 0.96; 95% confidence interval 0.76-1.21). Milrinone did not significantly affect other patient-centred outcomes. All analyses displayed statistical and/or clinical heterogeneity of patients, interventions, comparators, outcomes, and/or settings and all featured missing data. DISCUSSION The current evidence on the use of milrinone in critically ill adult patients with cardiac dysfunction suffers from considerable risks of both bias and random error and demonstrates no benefits. The use of milrinone for the treatment of critically ill patients with cardiac dysfunction can be neither recommended nor refuted. Future randomised clinical trials need to be sufficiently large and designed to have low risk of bias.
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Affiliation(s)
- Geert Koster
- Department of Critical Care, University of Groningen, University Medical Centre Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands.
| | - Hanneke J Bekema
- Department of Anaesthesiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Jørn Wetterslev
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital, 2100, Copenhagen, Denmark
| | - Christian Gluud
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital, 2100, Copenhagen, Denmark
| | - Frederik Keus
- Department of Critical Care, University of Groningen, University Medical Centre Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Iwan C C van der Horst
- Department of Critical Care, University of Groningen, University Medical Centre Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
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You Z, Huang L, Cheng X, Wu Q, Jiang X, Wu Y. Effect of milrinone on cardiac functions in patients undergoing coronary artery bypass graft: a meta-analysis of randomized clinical trials. DRUG DESIGN DEVELOPMENT AND THERAPY 2016; 10:53-8. [PMID: 26766900 PMCID: PMC4699515 DOI: 10.2147/dddt.s77464] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background and aim Inotropes are commonly used to treat myocardial dysfunction, which is the major complication after coronary artery bypass graft (CABG). Milrinone, a phosphodiesterase 3 inhibitor, is one of these inotropes. Recently, a number of clinical studies have been carried out to evaluate the effects of milrinone on cardiac function in patients with low ventricular ejection fraction undergoing CABG. However, it has been inconclusive because of the inconsistent results. In addition, some studies found that milrinone increased the incidence of postoperative atrial arrhythmias and did not show any long-term beneficial effects on survival. Therefore, it is very important to perform a meta-analysis to summarize the results so as to determine the clinical efficacy and safety of milrinone. Method Several databases and websites for clinical trials were searched until October 2015 for prospective clinical studies comparing milrinone versus placebo on cardiac functions in patients undergoing CAGB. Results Four articles were identified by our search strategy. 1) Milrinone decreased incidence of myocardial ischemia and myocardial infarction (15.6% versus 44.4%; 4.7% versus 18% in milrinone and control group, respectively). 2) Milrinone decreased duration of inotropic support (95% confidence interval [CI]: −6.52 to −1.68; P=0.0009) and mechanical ventilation (h) support (95% CI −5.00 to −0.69; P=0.010), but did not decrease the requirement for intra-aortic balloon pump or inotropic support (P>0.05). 3) Milrinone did not decrease the overall mortality or morbidity, intensive care unit stay (P>0.05). Conclusion Perioperative continuous infusion of milrinone is effective to lower incidence of myocardial ischemia and myocardial infarction in patients post-CABG, but it was unable to improve the overall morbidity and mortality or decreased duration of intensive care unit stay. The available sample size is small; therefore, future studies should be directed toward a better understanding of the benefit of milrinone to CABG patients.
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Affiliation(s)
- Zhigang You
- Department of Cardiology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People's Republic of China
| | - Lin Huang
- Department of Cardiology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People's Republic of China
| | - Xiaoshu Cheng
- Department of Cardiology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People's Republic of China
| | - Qinghua Wu
- Department of Cardiology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People's Republic of China
| | - Xinghua Jiang
- Department of Cardiology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People's Republic of China
| | - Yanqing Wu
- Department of Cardiology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People's Republic of China
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Balzer F, Sander M, Simon M, Spies C, Habicher M, Treskatsch S, Mezger V, Schirmer U, Heringlake M, Wernecke KD, Grubitzsch H, von Heymann C. High central venous saturation after cardiac surgery is associated with increased organ failure and long-term mortality: an observational cross-sectional study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:168. [PMID: 25888321 PMCID: PMC4415351 DOI: 10.1186/s13054-015-0889-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Accepted: 03/17/2015] [Indexed: 01/20/2023]
Abstract
INTRODUCTION Central venous saturation (ScvO2) monitoring has been suggested to address the issue of adequate cardiocirculatory function in the context of cardiac surgery. The aim of this study was to determine the impact of low (L) (<60%), normal (N) (60%-80%), and high (H) (>80%) ScvO2 measured on intensive care unit (ICU) admission after cardiac surgery. METHODS We conducted a retrospective, cross-sectional, observational study at three ICUs of a university hospital department for anaesthesiology and intensive care. Electronic patient records of all adults who underwent cardiac surgery between 2006 and 2013 and available admission measurements of ScvO2 were examined. Patients were allocated to one of three groups according to first ScvO2 measurement after ICU admission: group L (<60%), group N (60%-80%), and group H (>80%). Primary end-points were in-hospital and 3-year follow-up survival. RESULTS Data from 4,447 patients were included in analysis. Low and high initial measurements of ScvO2 were associated with increased in-hospital mortality (L: 5.6%; N: 3.3%; H: 6.8%), 3-year follow-up mortality (L: 21.6%; N: 19.3%; H: 25.8%), incidence of post-operative haemodialysis (L: 11.5%; N: 7.8%; H: 15.3%), and prolonged hospital length of stay (L: 13 days, 9-22; N: 12 days, 9-19; H: 14 days, 9-21). After adjustment for possible confounding variables, an initial ScvO2 above 80% was associated with adjusted hazard ratios of 2.79 (95% confidence interval (CI) 1.565-4.964, P <0.001) for in-hospital survival and 1.31 (95% CI 1.033-1.672, P = 0.026) for 3-year follow-up survival. CONCLUSIONS Patients with high ScvO2 were particularly affected by unfavourable outcomes. Advanced haemodynamic monitoring may help to identify patients with high ScvO2 who developed extraction dysfunction and to establish treatment algorithms to improve patient outcome in these patients.
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Affiliation(s)
- Felix Balzer
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Charité, Campus Charité Mitte/Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10098, Berlin, Germany.
| | - Michael Sander
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Charité, Campus Charité Mitte/Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10098, Berlin, Germany.
| | - Mark Simon
- Department of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Erlanger Allee 101, 07747, Jena, Germany.
| | - Claudia Spies
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Charité, Campus Charité Mitte/Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10098, Berlin, Germany.
| | - Marit Habicher
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Charité, Campus Charité Mitte/Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10098, Berlin, Germany.
| | - Sascha Treskatsch
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Charité, Campus Charité Mitte/Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10098, Berlin, Germany.
| | - Viktor Mezger
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Charité, Campus Charité Mitte/Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10098, Berlin, Germany.
| | - Uwe Schirmer
- Institute of Anaesthesiology Heart and Diabetes Center Nordrhein-Westfalen, University Clinic Ruhr-University Bochum, Georgstrasse 11, 32545, Bad Oeynhausen, Germany.
| | - Matthias Heringlake
- Department of Anaesthesiology and Intensive Care Medicine, University of Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany.
| | | | - Herko Grubitzsch
- Department of Cardiovascular Surgery, University Hospital Charité, Campus Charité Mitte/Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10098, Berlin, Germany.
| | - Christian von Heymann
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Charité, Campus Charité Mitte/Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10098, Berlin, Germany.
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Oualha M, Urien S, Spreux-Varoquaux O, Bordessoule A, D'Agostino I, Pouard P, Tréluyer JM. Pharmacokinetics, hemodynamic and metabolic effects of epinephrine to prevent post-operative low cardiac output syndrome in children. Crit Care 2014; 18:R23. [PMID: 24456639 PMCID: PMC4056810 DOI: 10.1186/cc13707] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2013] [Accepted: 01/09/2014] [Indexed: 11/16/2022] Open
Abstract
Introduction The response to exogenous epinephrine (Ep) is difficult to predict given the multitude of factors involved such as broad pharmacokinetic and pharmacodynamic between-subject variabilities, which may be more pronounced in children. We investigated the pharmacokinetics and pharmacodynamics of Ep, co-administered with milrinone, in children who underwent open heart surgical repair for congenital defects following cardiopulmonary bypass, including associated variability factors. Methods Thirty-nine children with a high risk of low cardiac output syndrome were prospectively enrolled. Ep pharmacokinetics, hemodynamic and metabolic effects were analyzed using the non-linear mixed effects modeling software MONOLIX. According to the final model, an Ep dosing simulation was suggested. Results Ep dosing infusions ranged from 0.01 to 0.23 μg.kg-1.min-1 in children whose weight ranged from 2.5 to 58 kg. A one-compartment open model with linear elimination adequately described the Ep concentration-time courses. Bodyweight (BW) was the main covariate influencing clearance (CL) and endogenous Ep production rate (q0) via an allometric relationship: CL(BWi) = θCL x (BWi)3/4 and q0(BWi) = θq0 x (BWi )3/4. The increase in heart rate (HR) and mean arterial pressure (MAP) as a function of Ep concentration were well described using an Emax model. The effect of age was significant on HR and MAP basal level parameters. Assuming that Ep stimulated the production rate of plasma glucose, the increases in plasma glucose and lactate levels were well described by turnover models without any significant effect of age, BW or exogenous glucose supply. Conclusions According to this population analysis, the developmental effects of BW and age explained a part of the pharmacokinetic and pharmacodynamics between-subject variabilities of Ep administration in critically ill children. This approach ultimately leads to a valuable Ep dosing simulation which should help clinicians to determine an appropriate a priori dosing regimen.
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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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15
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COLDING PD, KOLSTRUP LM, HYLDEBRANDT JA, SCHMIDT MR, BØTKER HE, RAVN HB. Metabolic effects of three different inotropic strategies in the newborn piglet myocardium. Acta Anaesthesiol Scand 2013. [PMID: 23186323 DOI: 10.1111/aas.12005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Neonates undergoing congenital heart surgery frequently need post-operative inotropic support. Knowledge about the effect of inotropes on myocardial metabolism in the newborn heart is limited, and the choice of inotropic therapy is based mainly on evidence from studies in adults. The aim of this study was to compare the effect of three inotropic strategies on the myocardial metabolism in a neonatal pig model. METHODS Newborn piglets were randomised to intravenous infusions with: adrenaline and milrinone; dopamine and milrinone; dobutamine in haemodynamically equivalent doses; or isotonic saline, through 3 h. Microdialysis catheters were inserted in the myocardium of the left and right ventricle, and concentrations of lactate, pyruvate, glycerol, and glucose were measured in the microdialysate. In myocardial biopsies, tissue lactate and intracellular glycogen concentrations were determined, and arterial blood samples were analysed for lactate and glucose. RESULTS No statistically significant differences were observed in haemodynamics between the three interventions. Metabolic variables demonstrated a consistent increase in lactate concentration in blood, myocardial dialysate, and biopsies in milrinone-adrenaline-treated animals. The lactate concentration remained stable in all other groups in all samples. The myocardial lactate/pyruvate ratio did not increase and was not significantly different between groups. CONCLUSION Milrinone and adrenaline induced significantly higher lactate levels in neonatal piglets. The increase was not caused by myocardial ischaemia, but rather due to a beta-stimulation-induced glycolysis.
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Affiliation(s)
- P. D. COLDING
- Department of Anaesthesiology and Intensive Care Medicine; Aarhus University Hospital; Skejby; Denmark
| | - L. M. KOLSTRUP
- Department of Anaesthesiology and Intensive Care Medicine; Aarhus University Hospital; Skejby; Denmark
| | | | - M. R. SCHMIDT
- Department of Cardiology; Aarhus University Hospital; Skejby; Denmark
| | - H. E. BØTKER
- Department of Cardiology; Aarhus University Hospital; Skejby; Denmark
| | - H. B. RAVN
- Department of Anaesthesiology and Intensive Care Medicine; Aarhus University Hospital; Skejby; Denmark
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Majure DT, Greco T, Greco M, Ponschab M, Biondi-Zoccai G, Zangrillo A, Landoni G. Meta-analysis of Randomized Trials of Effect of Milrinone on Mortality in Cardiac Surgery: An Update. J Cardiothorac Vasc Anesth 2013; 27:220-9. [PMID: 23063100 DOI: 10.1053/j.jvca.2012.08.005] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Indexed: 02/08/2023]
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Bracht H, Calzia E, Georgieff M, Singer J, Radermacher P, Russell JA. Inotropes and vasopressors: more than haemodynamics! Br J Pharmacol 2012; 165:2009-11. [PMID: 22074274 DOI: 10.1111/j.1476-5381.2011.01776.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Circulatory shock is characterized by arterial hypotension requiring fluid resuscitation combined with inotropes and/or vasopressors to correct the otherwise life-threatening impairment of oxygen supply to peripheral tissues. Catecholamines represent the current therapeutic choice, but this standard is only based on empirical clinical experience. Although there is evidence that some catecholamines may be better than others, it is a matter of debate which one may be the most effective and/or the safest for the different situations. In their review in this issue of the British Journal of Pharmacology, Bangash et al. provide an overview of the pharmacology as well as the available clinical data on the therapeutic use of endogenous catecholamines, their synthetic derivatives and a range of other agents (vasopressin and its analogues, PDE inhibitors and levosimendan). The authors point out that, despite well-established receptor pharmacology, the clinical effects of these treatments are poorly understood. Hence, further investigations are essential to determine which catecholamine, or, in a broader sense, which alternative vasopressor and/or inotrope is the most appropriate for a particular clinical condition.
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Affiliation(s)
- Hendrik Bracht
- Klinik für Anästhesiologie, Universitätsklinikum, Ulm, Germany
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18
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Larach DB, Kofke WA, Le Roux P. Potential non-hypoxic/ischemic causes of increased cerebral interstitial fluid lactate/pyruvate ratio: a review of available literature. Neurocrit Care 2012; 15:609-22. [PMID: 21336786 DOI: 10.1007/s12028-011-9517-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Microdialysis, an in vivo technique that permits collection and analysis of small molecular weight substances from the interstitial space, was developed more than 30 years ago and introduced into the clinical neurosciences in the 1990s. Today cerebral microdialysis is an established, commercially available clinical tool that is focused primarily on markers of cerebral energy metabolism (glucose, lactate, and pyruvate) and cell damage (glycerol), and neurotransmitters (glutamate). Although the brain comprises only 2% of body weight, it consumes 20% of total body energy. Consequently, the ability to monitor cerebral metabolism can provide significant insights during clinical care. Measurements of lactate, pyruvate, and glucose give information about the comparative contributions of aerobic and anaerobic metabolisms to brain energy. The lactate/pyruvate ratio reflects cytoplasmic redox state and thus provides information about tissue oxygenation. An elevated lactate pyruvate ratio (>40) frequently is interpreted as a sign of cerebral hypoxia or ischemia. However, several other factors may contribute to an elevated LPR. This article reviews potential non-hypoxic/ischemic causes of an increased LPR.
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Affiliation(s)
- Daniel B Larach
- University of Pennsylvania School of Medicine, Philadelphia, PA, USA.
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Resumen del documento de consenso «Guías de práctica clínica para el manejo del síndrome de bajo gasto cardiaco en el postoperatorio de cirugía cardiaca». Med Intensiva 2012; 36:277-87. [DOI: 10.1016/j.medin.2012.01.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2011] [Revised: 12/17/2011] [Accepted: 01/07/2012] [Indexed: 11/18/2022]
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Pérez Vela J, Martín Benítez J, Carrasco González M, De la Cal López M, Hinojosa Pérez R, Sagredo Meneses V, del Nogal Saez F. Guías de práctica clínica para el manejo del síndrome de bajo gasto cardíaco en el postoperatorio de cirugía cardíaca. Med Intensiva 2012; 36:e1-44. [DOI: 10.1016/j.medin.2012.02.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2011] [Accepted: 01/07/2012] [Indexed: 01/04/2023]
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Zangrillo A, Biondi-Zoccai G, Ponschab M, Greco M, Corno L, Covello RD, Cabrini L, Bignami E, Melisurgo G, Landoni G. Milrinone and Mortality in Adult Cardiac Surgery: A Meta-analysis. J Cardiothorac Vasc Anesth 2012; 26:70-7. [PMID: 21943792 DOI: 10.1053/j.jvca.2011.06.022] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2011] [Indexed: 02/08/2023]
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Abstract
PURPOSE OF REVIEW In surgical patients, outcome is strictly dependent on the occurrence of postoperative complications, and a postoperative failing kidney has a significant independent effect on outcome. Acute kidney injury (AKI) occurs in 1% of noncardiac surgical patients and is commonly associated with more serious complications. It is important to prevent AKI wherever possible. RECENT FINDINGS The mainstay of postoperative AKI prevention is perioperative maintenance of blood volume with adequate cardiac output by hemodynamic monitoring and fluids/inotropes infusion. There is a growing interest for pharmacological and metabolic interventions. Most interventions, however, have been predominantly evaluated in cardiac surgery and no definite conclusion can be translated in other settings. Tight control of glycemia is still matter of debate and a role, if any, may be limited to cardiac surgical patients. SUMMARY Adopting adequate nephroprotective strategies is favored by knowing the moment of the actual insult to the kidney. Nevertheless, in the literature too many areas of uncertainty still exist due to the lack of renal risk stratification, of adequately powered studies, of uniform AKI definition, and of appropriate sample composition. The only recommendation for renal protection still consists in maintaining an optimal blood volume and an adequate cardiac output.
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Chase JG, Starfinger C, Hann CE, Revie JA, Stevenson D, Shaw GM, Desaive T. Model-based prediction of the patient-specific response to adrenaline. Open Med Inform J 2010; 4:149-63. [PMID: 21603091 PMCID: PMC3098554 DOI: 10.2174/1874431101004010149] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2009] [Revised: 02/02/2010] [Accepted: 05/03/2010] [Indexed: 11/22/2022] Open
Abstract
A model for the cardiovascular and circulatory systems has previously been validated in simulated cardiac and circulatory disease states. It has also been shown to accurately capture the main hemodynamic trends in porcine models of pulmonary embolism and PEEP (positive end-expiratory pressure) titrations at different volemic levels. In this research, the existing model and parameter identification process are used to study the effect of different adrenaline doses in healthy and critically ill patient populations, and to develop a means of predicting the hemodynamic response to adrenaline. The hemodynamic effects on arterial blood pressures and stroke volume (cardiac index) are simulated in the model and adrenaline-specific parameters are identified. The dose dependent changes in these parameters are then related to adrenaline dose using data from studies published in the literature. These relationships are then used to predict the future, patient-specific response to a change in dose or over time periods from 1-12 hours. The results are compared to data from 3 published adrenaline dosing studies comprising a total of 37 data sets. Absolute percentage errors for the identified model are within 10% when re-simulated and compared to clinical data for all cases. All identified parameter trends match clinically expected changes. Absolute percentage errors for the predicted hemodynamic responses (N=15) are also within 10% when re-simulated and compared to clinical data. Clinically accurate prediction of the effect of inotropic circulatory support drugs, such as adrenaline, offers significant potential for this type of model-based application. Overall, this work represents a further clinical, proof of concept, of the underlying fundamental mathematical model, methods and approach, as well as providing a template for using the model in clinical titration of adrenaline in a decision support role in critical care. They are thus a further justification in support of upcoming human clinical trials to validate this model.
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Affiliation(s)
- J. Geoffrey Chase
- Centre for Bioengineering, University of Canterbury, Christchurch, New Zealand
| | | | - Christopher E Hann
- Centre for Bioengineering, University of Canterbury, Christchurch, New Zealand
| | - James A Revie
- Centre for Bioengineering, University of Canterbury, Christchurch, New Zealand
| | - Dave Stevenson
- Centre for Bioengineering, University of Canterbury, Christchurch, New Zealand
| | - Geoffrey M Shaw
- Department of Intensive Care Medicine, Christchurch Hospital, Christchurch, New Zealand
| | - Thomas Desaive
- Cardiovascular Research Center, University of Liege, Belgium
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Jakob SM, Stanga Z. Perioperative metabolic changes in patients undergoing cardiac surgery. Nutrition 2010; 26:349-53. [PMID: 20053534 DOI: 10.1016/j.nut.2009.07.014] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2009] [Accepted: 07/21/2009] [Indexed: 01/10/2023]
Abstract
Perioperative metabolic changes in cardiac surgical patients are not only induced by tissue injury and extracorporeal circulation per se: the systemic inflammatory response to surgical trauma and extracorporeal circulation, perioperative hypothermia, cardiovascular and neuroendocrine responses, and drugs and blood products used to maintain cardiovascular function and anesthesia contribute to varying degrees. The pathophysiologic changes include increased oxygen consumption and energy expenditure; increased secretion of adrenocorticotrophic hormone, cortisol, epinephrine, norepinephrine, insulin, and growth hormone; and decreased total tri-iodothyronine levels. Easily measurable metabolic consequences of these changes include hyperglycemia, hyperlactatemia, increased aspartate, glutamate and free fatty acid concentrations, hypokalemia, increased production of inflammatory cytokines, and increased consumption of complement and adhesion molecules. Nutritional risk before elective cardiac surgery-defined as preoperative unintended pathologic weight loss/low amount of food intake in the preceding week or low body mass index-is related to adverse postoperative outcome. Improvements in surgical techniques, anesthesia, and perioperative management have been designed to minimize the stressful stimulus to catabolism, thereby slowing the wasting process to the point where much less nutrition is required to meet metabolic requirements. Early nutrition in cardiac surgery is safe and well tolerated.
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Affiliation(s)
- Stephan M Jakob
- Department of Intensive Care Medicine, Bern University Hospital and University of Bern, Bern, Switzerland.
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Pathophysiologie, Prophylaxe und Therapie von Herzchirurgie-assoziierten Nierenfunktionsstörungen. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2009. [DOI: 10.1007/s00398-009-0743-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Does perioperative hemodynamic optimization protect renal function in surgical patients? A meta-analytic study. Crit Care Med 2009; 37:2079-90. [PMID: 19384211 DOI: 10.1097/ccm.0b013e3181a00a43] [Citation(s) in RCA: 252] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Postoperative acute deterioration in renal function, producing oliguria and/or increase in serum creatinine, is one of the most serious complication in surgical patients. Most cases are due to renal hypoperfusion as a consequence of systemic hypotension, hypovolemia, and cardiac dysfunction. Although some evidence suggests that perioperative monitoring and manipulation of oxygen delivery by volume expansion and inotropic drugs may decrease mortality in surgical patients, no study analyzed this approach on postoperative renal dysfunction. The objective of this investigation is to perform a meta-analysis on the effects of perioperative hemodynamic optimization on postoperative renal dysfunction. DATA SOURCES, STUDY SELECTION, DATA EXTRACTION: A systematic literature review, using MEDLINE, EMBASE, and The Cochrane Library databases through January 2008 was conducted and 20 studies met the inclusion criteria (4220 participants). Data synthesis was obtained by using odds ratio (OR) with 95% confidence interval (CI) by random-effects model. DATA SYNTHESIS Postoperative acute renal injury was significantly reduced by perioperative hemodynamic optimization when compared with control group (OR 0.64; CI 0.50-0.83; p = 0.0007). Perioperative optimization was effective in reducing renal injury defined consistently with risk, injury, failure, and loss and end-stage kidney disease and Acute Kidney Injury Network classifications, and in studies defining renal dysfunction by serum creatinine and/or need of renal replacement therapy only (OR 0.66; CI 0.50-0.88; p = 0.004). The occurrence of renal dysfunction was reduced when treatment started both preoperatively and intraoperatively or postoperatively, was performed in high-risk patients, and was obtained by fluids and inotropes. Mortality was significantly reduced in treatment group (OR 0.50; CI 0.31-0.80; p = 0.004), but statistical heterogeneity was observed. CONCLUSIONS Surgical patients receiving perioperative hemodynamic optimization are at decreased risk of renal impairment. Because of the impact of postoperative renal complications on adverse outcome, efforts should be aimed to identify patients and surgery that would most benefit from perioperative optimization.
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Arbeus M, Axelsson B, Friberg O, Magnuson A, Bodin L, Hultman J. Milrinone increases flow in coronary artery bypass grafts after cardiopulmonary bypass: a prospective, randomized, double-blind, placebo-controlled study. J Cardiothorac Vasc Anesth 2008; 23:48-53. [PMID: 18834820 DOI: 10.1053/j.jvca.2008.07.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2008] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To compare the effects of a bolus of milrinone, 50 microg/kg, versus placebo on flow in coronary artery bypass grafts after cardiopulmonary bypass (CPB). DESIGN A prospective, randomized, double-blind study. SETTING A university hospital. PARTICIPANTS Forty-four patients with stable angina and left ventricular ejection fraction >30% scheduled for elective coronary artery bypass graft (CABG) surgery were included. INTERVENTION Patients were randomized to receive 50 microg/kg of milrinone (n = 22) or placebo (n = 22) after aortic declamping. MEASUREMENTS AND MAIN RESULTS The flow in coronary artery bypass grafts was measured with a transit time flow meter at 10 minutes and 30 minutes after termination of CPB. The hemodynamic evaluation included transesophageal echocardiography, mean arterial pressure (MAP), heart rate, and intracavitary measurement of left ventricular end-diastolic pressure (LVEDP). The flow in the saphenous vein grafts was significantly higher in the milrinone group when compared with the placebo group both at 10 and 30 minutes after termination of CPB (p < 0.001). At 10 minutes, the flow was 64.5 +/- 37.4 mL/min (mean +/- standard deviation) and 43.6 +/- 25.7 mL/min in nonsequential vein grafts for milrinone and placebo, respectively. Corresponding values at 30 minutes were 54.8 +/- 29.9 mL/min and 35.3 +/- 22.4 mL/min. The left internal thoracic artery (LITA) flow was higher in the milrinone group but did not reach statistical significance. The fractional area change was higher, and the MAP and calculated pressure gradient (MAP-LVEDP) were lower at 10 minutes in the milrinone group. CONCLUSION Milrinone significantly increases the flow in anastomosed saphenous vein grafts after CPB, and has beneficial effects on left ventricular function.
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Affiliation(s)
- Mikael Arbeus
- Department of Cardiothoracic Surgery and Anesthesiology, Orebro University Hospital, Orebro, Sweden.
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Simkova V, Radermacher P, Barth E. Metabolic effects of phosphodiesterase III inhibitors: another reason to promote their use? Crit Care 2007; 11:139. [PMID: 17572916 PMCID: PMC2206415 DOI: 10.1186/cc5924] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Phosphodiesterase III inhibitors combine positive inotropic and vasodilator properties. These inhibitors are therefore frequently used to treat low cardiac output and/or severe left heart failure associated with cardiac surgery. Their effects on energy metabolism and visceral organ function are not well studied, however, particularly in comparison with their 'competitors' in daily practice (that is, catecholamines).
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Affiliation(s)
- Vladislava Simkova
- Sektion Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum, Parkstrasse 11, D-89073 Ulm, Germany
- Anesteziologicko-resuscitacni klinika, Fakultni nemocnice u sv Anny, Brno, Czech Republic
| | - Peter Radermacher
- Sektion Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum, Parkstrasse 11, D-89073 Ulm, Germany
| | - Eberhard Barth
- Sektion Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum, Parkstrasse 11, D-89073 Ulm, Germany
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