Is There Still a Place for Dopamine in the Modern Intensive Care Unit?

Standardized Solutions of Catecholamines in Intensive Care Medicine: Application, Safety and Economic Aspects

Background/Objectives: Catecholamines are among those agents that are indispensable in modern intensive care medicine. The rapid availability of hygienically impeccable and correctly concentrated injectable solutions, e.g., for syringe pumps, is becoming more and more important. However, little research has been conducted regarding how the use of catecholamines is distributed in different wards and what options can be used to achieve optimal availability. Methods: In a retrospective monocentric study from 2019 to 2022, all continuously applied catecholamines in intensive care units (ICU) and intermediate care units (IMC) were investigated. The focus was on potential optimization by utilizing manufactured ready-to-administer solutions in the context of the economization of patient care. Results: Norepinephrine syringes represented 81% of all syringes administered, appearing to be the most frequently used on all wards. Production by the in-house pharmacy showed both financial advantages and an increase in patient safety compared to syringes produced at the bedside. Discussion: Increasing numbers of critically ill patients coupled with growing staff shortages and an increased awareness of safety requirements are driving the move towards ready-to-use and ready-to-administer solutions in critical care medicine. In-house manufacturing by hospital pharmacies can be a promising option to optimize processes and improve the economics of patient care. Conclusions: Individual calculations of the required catecholamine preparations with regard to possible economic advantages should be carried out in hospitals. In particular, in-house production of ready-to-use and ready-to-administer preparations could significantly increase patient safety and seems to be economically viable.

Analysis of the Association Between the Number of Intensivists and the Use of Cardiovascular Agonists: An Ecological Study Using Data From National Databases of Japan

Background Previous studies have demonstrated a correlation between management by intensivists and a decrease in hospital stay and mortality, yet the underlying reason remains unknown. Using open data from the National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB) and other databses, the present study aimed to explore the relationship between inotrope and vasoconstrictor use and the number of intensivists. Materials and methods Cardiovascular agonists listed in the 2020 NDB for which the total dose was known were included for analysis. Trends in cardiovascular agonist use over six years were then graphically assessed, and a linear regression model with the use of each target drug per prefecture as the objective variable in the 2020 data was created to analyze the impact of intensivists on drug use. Results A total of 61 drugs were classified into eight groups based on their composition, and drug use in each of the 47 prefectures was tabulated. Both the rate of use and cost showed a yearly decrease for dopamine but a yearly increase for norepinephrine. Multivariable analysis indicated that the number of intensivists was only significant for dopamine, which had a coefficient of -310 (95% CI: -548 to -72, p = 0.01) but that no such trend was evident for the other drugs. Conclusions The results demonstrated that an increasing number of intensivists in each prefecture correlated with decreasing use of dopamine, possibly explaining the improved outcomes observed in closed ICUs led by intensivists. Further research is warranted to establish causality.

Dopamine use and its consequences in the intensive care unit: a cohort study utilizing the Japanese Intensive care PAtient Database

Background

Dopamine is used to treat patients with shock in intensive care units (ICU) throughout the world, despite recent evidence against its use. The aim of this study was to identify the latest practice of dopamine use in Japan and also to explore the consequences of dopamine use in a large Asian population.

Methods

The Japanese Intensive Care PAtient Database (JIPAD), the largest intensive care database in Japan, was utilized. Inclusion criteria included: 1) age 18 years or older, 2) admitted to the ICU for reasons other than procedures, 3) ICU length of stay of 24 h or more, and 4) treatment with either dopamine or noradrenaline within 24 h of admission. The primary outcome was in-hospital mortality. Multivariable regression analysis was performed, followed by a propensity score-matched analysis.

Results

Of the 132,354 case records, 14,594 records from 56 facilities were included in this analysis. Dopamine was administered to 4,653 patients and noradrenaline to 11,844. There was no statistically significant difference in facility characteristics between frequent dopamine users (N = 28) and infrequent users (N = 28). Patients receiving dopamine had more cardiovascular diagnosis codes (70% vs. 42%; p < 0.01), more post-elective surgery status (60% vs. 31%), and lower APACHE III scores compared to patients given noradrenaline alone (70.7 vs. 83.0; p < 0.01). Multivariable analysis showed an odds ratio for in-hospital mortality of 0.86 [95% CI: 0.71–1.04] in the dopamine ≤ 5 μg/kg/min group, 1.46 [95% CI: 1.18–1.82] in the 5–15 μg/kg/min group, and 3.30 [95% CI: 1.19–9.19] in the > 15 μg/kg/min group. In a 1:1 propensity score matching for dopamine use as a vasopressor (570 pairs), both in-hospital mortality and ICU mortality were significantly higher in the dopamine group compared to no dopamine group (22.5% vs. 17.4%, p = 0.038; 13.3% vs. 8.8%, p = 0.018), as well as ICU length of stay (mean 9.3 days vs. 7.4 days, p = 0.004).

Conclusion

Dopamine is still widely used in Japan. The results of this study suggest detrimental effects of dopamine use specifically at a high dose.

Trial registration Retrospectively registered upon approval of the Institutional Review Board and the administration office of JIPAD.

Monitoring, management, and outcome of hypotension in Intensive Care Unit patients, an international survey of the European Society of Intensive Care Medicine

INTRODUCTION

Hypotension in the ICU is common, yet management is challenging and variable. Insight in management by ICU physicians and nurses may improve patient care and guide future hypotension treatment trials and guidelines.

METHODS

We conducted an international survey among ICU personnel to provide insight in monitoring, management, and perceived consequences of hypotension.

RESULTS

Out of 1464 respondents, 1197 (81.7%) were included (928 physicians (77.5%) and 269 nurses (22.5%)). The majority indicated that hypotension is underdiagnosed (55.4%) and largely preventable (58.8%). Nurses are primarily in charge of monitoring changes in blood pressure, physicians are in charge of hypotension treatment. Balanced crystalloids, dobutamine, norepinephrine, and Trendelenburg position were the most frequently reported fluid, inotrope, vasopressor, and positional maneuver used to treat hypotension. Reported complications believed to be related to hypotension were AKI and myocardial injury. Most ICUs do not have a specific hypotension treatment guideline or protocol (70.6%), but the majority would like to have one in the future (58.1%).

CONCLUSIONS

Both physicians and nurses report that hypotension in ICU patients is underdiagnosed, preventable, and believe that hypotension influences morbidity. Hypotension management is generally not protocolized, but the majority of respondents would like to have a specific hypotension management protocol.

Dopamine Receptors and the Kidney: An Overview of Health- and Pharmacological-Targeted Implications

The dopaminergic system can adapt to the different physiological or pathological situations to which the kidneys are subjected throughout life, maintaining homeostasis of natriuresis, extracellular volume, and blood pressure levels. The role of renal dopamine receptor dysfunction is clearly established in the pathogenesis of essential hypertension. Its associations with other pathological states such as insulin resistance and redox balance have also been associated with dysfunction of the dopaminergic system. The different dopamine receptors (D1-D5) show a protective effect against hypertension and kidney disorders. It is essential to take into account the various interactions of the dopaminergic system with other elements, such as adrenergic receptors. The approach to therapeutic strategies for essential hypertension must go through the blocking of those elements that lead to renal vasoconstriction or the restoration of the normal functioning of dopamine receptors. D1-like receptors are fundamental in this role, and new therapeutic efforts should be directed to the restoration of their functioning in many patients. More studies will be needed to allow the development of drugs that can be targeted to renal dopamine receptors in the treatment of hypertension.

Sympathomimetics in veterinary species under anesthesia

Sympathomimetic drugs mimic the physiological action of the sympathetic nervous system through interaction with adrenergic receptors. These drugs are commonly used to provide cardiovascular support in many veterinary species. Despite their common use, the literature evaluating their effectiveness can be somewhat limited depending on the species. This review details the mechanism of action of various sympathomimetic drugs and summarizes the literature that is available describing the efficacy of these drugs and their use in anesthetized veterinary species.

Serum Lactate as an Independent Predictor of In-Hospital Mortality in Intensive Care Patients

PURPOSE

The aim of this study was to check if serum lactate was independently associated with mortality among critically ill patients.

MATERIALS AND METHODS

This was a single-center, retrospective cohort study. All adult patients (>18 years of age) who had at least 1 measurement of lactate within 24 hours of admission to intensive care unit (ICU) between January 2002 and December 2017 were included in the analysis. Patients were stratified into 3 groups: those with a serum lactate of <2 mmol/L (normal level), 2 to 4 mmol/L (intermediate level), and >4 mmol/L (high level). The primary outcome was in-hospital mortality. Secondary outcomes included ICU and hospital lengths of stay and mechanical ventilation duration. To determine the association between lactate level and hospital mortality, bivariate and multivariate logistic regression analyses were performed.

RESULTS

Of the 16,447 patients admitted to the ICU, 8167 (49.65%) had normal levels, 4648 (28.26%) had an intermediate, and 3632 (22.09%) had high lactate levels. Hospital mortality was the highest in high lactate level, followed by the intermediate and the normal level group (47.4% vs 26.5% vs 19.6%; P < .0001). Intermediate and high lactate levels were independent predictors of hospital mortality (odds ratio [OR], 1.32; 95% confidence interval [CI]: 1.20-1.46, and 1.94; 95% CI, 1.75-2.16, respectively) as well as ICU mortality (OR, 1.47; 95% CI, 1.30-1.66 and 2.56; 95% CI, 2.27-2.88, respectively).

CONCLUSIONS

Intensive care unit serum lactate is associated with increased ICU and hospital mortality, independent of comorbidities, organ dysfunction, or hemodynamic status.

Acute Kidney Injury after Cardiac Surgery: Risk Factors and Novel Biomarkers

Acute kidney injury (AKI) is a common and severe complication after cardiac surgery. Currently, a series of novel biomarkers have favored the assessment of AKI after cardiac surgery in addition to the conventional indicators. The biomartkers, such as urinary liver fatty acid binding protein (L-FABP), urinary neutrophil gelatinase-associated lipocalin (NGAL), serum L-FABP, heart-type FABP, kidney injury molecule 1 (KIM-1), and interleukin-18 were found to be significantly higher in patients who developed AKI after cardiac surgery than those who did not. Apart from urinary interleukin-18, the novel biomarkers have been recognized as reliable indicators for predicting the diagnosis, adverse outcome, and even mortality of AKI after cardiac surgery. The timing of the renal replacement therapy is a significant predictor relating to patients’ prognoses. In patients with AKI after cardiac surgery, renal replacement therapy should be performed as early as possible in order to achieve promising outcomes. In children, AKI after cardiac surgery can be managed with peritoneal dialysis. AKI after cardiac surgery has received extensive attention as it may increase early mortality and impact long-term survival of patients as well. The purpose of this article was to analyze the changes of the pertinent biomarkers, to explore the related risk factors leading to the occurrence of AKI after cardiac surgery, and to provide a basis for the clinical prevention and reduction of AKI.

Renal Insufficiency After Cardiac Surgery

The new millennium ushered in a number of changes in cardiac surgery. Off-pump coronary artery bypass surgery became technically easier so that multivessel surgery became less of a challenge and cardiologists were supplied with new catheters that accessed lesions that were previously thought of as being unapproachable. New drugs were introduced that made the management of heart failure patients feasible on an outpatient basis, and new devices extend the bridging period to transplantation. However, these advances have not necessarily been attended by significant improvements in outcome, possibly because the less challengng a procedure becomes, the sicker the patients that can be managed. This observation is particularly true with the incidence and outcome of renal failure after cardiac surgery. Bypass factors have been manipulated without much effect, and the traditional drugs that were found to increase renal blood flow in animal experiments did not translate into clinical improvement in renal outcome. Recent research has given us insight into the pathophysiology of ischemic acute renal failure, and it has been found that the paradigm was not as simple as previously thought, possibly accounting for the failure of the more traditional renal drugs (dopamine, mannitol and diuretics). However, these new insights open up the possibility of novel targets for renal protection and repair.

Renal-Dose Dopamine: From Hypothesis to Paradigm to Dogma to Myth and, Finally, Superstition?

Acute renal failure (ARF) is common in the critically ill and is associated with a high mortality rate. Its pathogenesis is not understood. Because animal models use ischemia to induce experimental ARF, there is the widespread belief that lack of blood flow is responsible for ARF. Low-dose dopamine (LDD) has been shown to increase renal blood flow in animal and in human volunteers. Thus, it has been administered to humans for almost 3 decades in the belief that it would lead to renal arterial vasodilation and increase renal blood flow (RBF). However, the etiology of ARF in critical illness is likely multifactorial, and the contribution of hypovolemia and reduced renal perfusion is unknown. Furthermore, interindividual variation in the pharmacokinetics of dopamine typically results in poor correlation between blood levels and administered dose, making accurate and reliable delivery of LDD difficult. Finally, dopamine is a proximal tubular diuretic that increases Na+ delivery to tubular cells, thus increasing their oxygen demands. Accordingly, even if LDD were able to preferentially increase RBF, there is no guarantee that it would restore renal parenchymal oxygen homeostasis. More important, 2 meta-analyses and a large double-blind, prospective, multiple-center, randomized controlled trial have failed to demonstrate that dopamine protects the kidney in critically ill patients with ARF. Currently, there is insufficient evidence to support the use of renal-dose dopamine in the intensive care unit.

Variables during Care of Adult Donors That Can Influence Outcomes of Kidney Transplantation

Publications that relate characteristics of donors to renal function of recipients are reviewed. Most publications report retrospective observations that relate outcomes to donor variables that cannot be altered during donor care. Factors that can be altered in adult donors in an effort to improve recipients' outcomes include urine output and creatinine level. Increasing urine output to more than 100 mL/h, at least during the hour before explantation, and returning the creatinine level to match its serum concentration when the patient was admitted can improve outcomes. Ways of accomplishing those goals during donor care are discussed, with emphasis on support of renal blood flow.

Postoperative management of heart failure in pediatric patients

Low cardiac output syndrome (LCOS) is a well-described entity occurring in 25-65% of pediatric patients undergoing open-heart surgery. With judicious intensive care management of LCOS, most patients have an uncomplicated postoperative course, and within 24 h after cardiopulmonary bypass, the cardiac function returns back to baseline. Some patients have severe forms of LCOS not responsive to medical management alone, requiring temporary mechanical circulatory support to prevent end-organ injury and to decrease myocardial stress and oxygen demand. Occasionally, cardiac function does not recover and heart transplantation is necessary. Long-term mechanical circulatory support devices are used as a bridge to transplantation because of limited availability of donor hearts. Experience in usage of continuous flow ventricular assist devices in the pediatric population is increasing.

Revisiting cAMP signaling in the carotid body

Chronic carotid body (CB) activation is now recognized as being essential in the development of hypertension and promoting insulin resistance; thus, it is imperative to characterize the chemotransduction mechanisms of this organ in order to modulate its activity and improve patient outcomes. For several years, and although controversial, cyclic adenosine monophosphate (cAMP) was considered an important player in initiating the activation of the CB. However, its relevance was partially displaced in the 90s by the emerging role of the mitochondria and molecules such as AMP-activated protein kinase and O₂-sensitive K⁺ channels. Neurotransmitters/neuromodulators binding to metabotropic receptors are essential to chemotransmission in the CB, and cAMP is central to this process. cAMP also contributes to raise intracellular Ca²⁺ levels, and is intimately related to the cellular energetic status (AMP/ATP ratio). Furthermore, cAMP signaling is a target of multiple current pharmacological agents used in clinical practice. This review (1) provides an outline on the classical view of the cAMP-signaling pathway in the CB that originally supported its role in the O₂/CO₂ sensing mechanism, (2) presents recent evidence on CB cAMP neuromodulation and (3) discusses how CB activity is affected by current clinical therapies that modify cAMP-signaling, namely dopaminergic drugs, caffeine (modulation of A_2A/A_2B receptors) and roflumilast (PDE4 inhibitors). cAMP is key to any process that involves metabotropic receptors and the intracellular pathways involved in CB disease states are likely to involve this classical second messenger. Research examining the potential modification of cAMP levels and/or interactions with molecules associated with CB hyperactivity is currently in its beginning and this review will open doors for future explorations.

Organ retrieval and banking in brain dead trauma patients: Our experience at level-1 trauma centre and current views

Background:

Organ retrieval from brain dead patients is getting an increased attention as the waiting list for organ recipients far exceeds the organ donor pool. In our country, despite a large population the number of brain dead donors undergoing organ donation is very less (2% in our study).

Aims:

The present study was undertaken to address issues related to organ donation and share our experience for the same.

Methods:

A retrospective case record analysis of over 5 years from September 2007 to August 2012 was performed and the patients fulfilling brain death criterion as per Transplantation of Human Organs and Tissue (Amendment) Act were included. Patient demographics (age, sex), mode of injury, time from injury to the diagnosis of brain death, time from diagnosis of brain death to organ retrieval and complications were analysed.

Statistics Analysis:

Student's t test was used for parametric data and Chi square was used for categorical data.

Results:

Out of 205 patients who were identified as brain dead, only 10 patients became potential organ donors.

Conclusion:

Aggressive donor management, increasing public awareness about the concept of organ donation, good communication between clinician and the family members and a well-trained team of transplant coordinators can help in improving the number of organ donations.

Critical care of the potential organ donor

Organ transplantation represents one of the great success stories of 20th century medicine. However, its continued success is greatly limited by the shortage of donor organs. This has led to an increased focus within the critical care community on optimal identification and management of the potential organ donor. The multi-organ donor can represent one of the most complex intensive care patients, with numerous competing physiological priorities. However, appropriate management of the donor not only increases the number of organs that can be successfully donated but has long-term implications for the outcomes of multiple recipients. This review outlines current understandings of the physiological derangements seen in the organ donor and evaluates the available evidence for management strategies designed to optimize donation potential and organ recovery. Finally, emerging management strategies for the potential donor are discussed within the current ethical and legal frameworks permitting donation after both brain and circulatory death.

The role of vasoactive agents in the resuscitation of microvascular perfusion and tissue oxygenation in critically ill patients

Purpose

The clinical use of vasoactive drugs is not only intended to improve systemic hemodynamic variables, but ultimately to attenuate derangements in organ perfusion and oxygenation during shock. This review aims (1) to discuss basic physiology with respect to manipulating vascular tone and its effect on the microcirculation, and (2) to provide an overview of available clinical data on the relation between vasoactive drugs and organ perfusion, with specific attention paid to recent developments that have enabled direct in vivo observation of the microcirculation and concepts that have originated from it.

Methods

A MedLine search was conducted for clinical articles in the English language over the last 15 years pertainig to shock, sepsis, organ failure, or critically ill patients in combination with vasoactive drugs and specific variables of organ perfusion/oxygenation (e.g., tonometry, indocyanine clearance, laser Doppler, and sidestream dark field imaging).

Results

Eighty original papers evaluating the specific relationship between organ perfusion/oxygenation and the use of vasoactive drugs were identified and are discussed in light of physiological theory of vasomotor tone.

Conclusions

Solid clinical data in support of the idea that increasing blood pressure in shock improves microcirculatory perfusion/oxygenation seem to be lacking, and such a concept might not be in line with physiological theory of microcirculation as a low-pressure vascular compartment. In septic shock no beneficial effect on microcirculatory perfusion above a mean arterial pressure of 65 mmHg has been reported, but a wide range in inter-individual effect seems to exist. Whether improvement of microcirculatory perfusion is associated with better patient outcome remains to be elucidated.

Drug-induced endocrine disorders in the intensive care unit

The neuroendocrine response to critical illness is key to the maintenance of homeostasis. Many of the drugs administered routinely in the intensive care unit significantly impact the neuroendocrine system. These agents can disrupt the hypothalamic-pituitary-adrenal axis, cause thyroid abnormalities, and result in dysglycemia. Herein, we review major drug-induced endocrine disorders and highlight some of the controversies that remain in this area. We also discuss some of the more rare drug-induced syndromes that have been described in the intensive care unit. Drugs that may result in an intensive care unit admission secondary to an endocrine-related adverse event are also included. Unfortunately, very few studies have systematically addressed drug-induced endocrine disorders in the critically ill. Timely identification and appropriate management of drug-induced endocrine adverse events may potentially improve outcomes in the critically ill. However, more research is needed to fully understand the impact of medications on endocrine function in the intensive care unit.

Prevention, diagnosis, therapy and follow-up care of sepsis: 1st revision of S-2k guidelines of the German Sepsis Society (Deutsche Sepsis-Gesellschaft e.V. (DSG)) and the German Interdisciplinary Association of Intensive Care and Emergency Medicine (Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin (DIVI))

Practice guidelines are systematically developed statements and recommendations that assist the physicians and patients in making decisions about appropriate health care measures for specific clinical circumstances taking into account specific national health care structures. The 1^st revision of the S-2k guideline of the German Sepsis Society in collaboration with 17 German medical scientific societies and one self-help group provides state-of-the-art information (results of controlled clinical trials and expert knowledge) on the effective and appropriate medical care (prevention, diagnosis, therapy and follow-up care) of critically ill patients with severe sepsis or septic shock. The guideline had been developed according to the “German Instrument for Methodological Guideline Appraisal” of the Association of the Scientific Medical Societies (AWMF). In view of the inevitable advancements in scientific knowledge and technical expertise, revisions, updates and amendments must be periodically initiated. The guideline recommendations may not be applied under all circumstances. It rests with the clinician to decide whether a certain recommendation should be adopted or not, taking into consideration the unique set of clinical facts presented in connection with each individual patient as well as the available resources.

Contemporary pharmacologic issues in the management of traumatic brain injury

Traumatic brain injury (TBI) is a major cause of death and disability in the United States. While there are no pharmacotherapeutic options currently available for attenuating the neurologic injury cascade after TBI, numerous pharmacologic issues are encountered in these critically ill patients. Adequate fluid resuscitation, reversal of coagulopathy, maintenance of cerebral perfusion, and treatment of intracranial hypertension are common interventions early in the treatment of TBI. Other deleterious complications such as venous thromboembolism, extremes in glucose concentrations, and stress-related mucosal disease should be anticipated and avoided. Early provision of nutrition and prevention of drug or alcohol withdrawal are also cornerstones of routine care in TBI patients. Prevention of infections and seizures may also be helpful. Clinicians caring for TBI patients should be familiar with the pharmacologic issues typical of this vulnerable population in order to develop optimal strategies of care to anticipate and prevent common complications.

Imbalance between thyroid hormones and the dopaminergic system might be central to the pathophysiology of restless legs syndrome: a hypothesis

Data collected from medical literature indicate that dopaminergic agonists alleviate Restless Legs Syndrome symptoms while dopaminergic agonists antagonists aggravate them. Dopaminergic agonists is a physiological regulator of thyroid-stimulating hormone. Dopaminergic agonists infusion diminishes the levels of thyroid hormones, which have the ability to provoke restlessness, hyperkinetic states, tremors, and insomnia. Conditions associated with higher levels of thyroid hormones, such as pregnancy or hyperthyroidism, have a higher prevalence of Restless Legs Syndrome symptoms. Low iron levels can cause secondary Restless Legs Syndrome or aggravate symptoms of primary disease as well as diminish enzymatic activities that are involved in dopaminergic agonists production and the degradation of thyroid hormones. Moreover, as a result of low iron levels, dopaminergic agonists diminishes and thyroid hormones increase. Iron therapy improves Restless Legs Syndrome symptoms in iron deprived patients. Medical hypothesis. To discuss the theory that thyroid hormones, when not counterbalanced by dopaminergic agonists, may precipitate the signs and symptoms underpinning Restless Legs Syndrome. The main cause of Restless Legs Syndrome might be an imbalance between the dopaminergic agonists system and thyroid hormones.

Critical care management of potential organ donors: our current standard

Caring for a brain dead potential organ donor requires a shift in critical care from the extensive treatment of increased intracranial pressure towards strategies to maintain donor organ function. Suboptimal, unstandardized critical care management of organ donors, however, is one of the main reasons for insufficient organ procurement. The pathophysiological changes following brain death entail a high incidence of complications including hemodynamic instability, endocrine and metabolic disturbances, and disruption of internal homeostasis that jeopardize potentially transplantable organs. Strategies for the management of organ donors exist and consist of the normalization of donor physiology. This has resulted in standardized efforts to improve the critical care delivered to potential organ donors, increasing not only the number, but also the quality of suitable organs and aiming at an optimal outcome for the recipients. In this review, we discuss the pathophysiological changes associated with brain death and present the current guidelines at our department, which are optimized based on available literature.

Update on donor assessment, resuscitation, and acceptance criteria, including novel techniques--non-heart-beating donor lung retrieval and ex vivo donor lung perfusion

The shortage of adequate organ donors remains a great challenge in clinical lung transplantation. With increasing experience in the medical management and surgical technique of lung transplantation, gradual expansion of the criteria for lung donor selection has occurred with beneficial effects on the donor pool. Interest in donation after cardiac death also is increasing as the gap increases between donors and the needs of listed patients. Successful use of these new sources of lungs depends on the accurate assessment and prediction of transplanted lung function. Promising techniques for lung assessment and diagnostics include investigating key genes associated with graft failure or good graft performance using molecular approaches, and ex vivo evaluation. Further studies are needed to answer remaining questions about the best technique and solution to reperfuse human lungs for several hours without edema formation. As the predictive ability to discern good from injured donor lungs improves, strategies to repair donor lungs become increasingly important. Prolonged normothermic EVLP seems to be a platform on which many reparative strategies can be realized. With these new methods for assessing and resuscitating lungs accurately, it is hoped that inroads will be made toward providing every listed patient a chance for successful lung transplantation.

[Sepsis therapy: present guidelines and their application]

Severe sepsis and septic shock have an increasing incidence and unchanged high mortality. Early diagnosis is necessary to slow the progression of organ dysfunction and improve outcome. Early administration of broad-spectrum antimicrobial therapy, early and aggressive hemodynamic therapy, and surgical source control are the most promising therapeutic approaches. Norepinephrine is the first choice as a vasopressor. Starches for volume resuscitation, intensive insulin therapy (aiming at 80-110 mg/dl), and low-dose hydrocortisone are not recommended outside randomized trials. Recombinant activated protein C is one choice for certain patients. The German Sepsis Competence Network (SepNet) is currently investigating other open questions.

Renal effects of fenoldopam in critically ill pediatric patients: A retrospective review

OBJECTIVE

Published data describe the use of fenoldopam in adults for treatment of oliguria/anuria and for renal perfusion and protection, but pediatric data are scant. We assessed the effects of fenoldopam on urine output and potential deleterious changes in hemodynamics or serum creatinine in children.

DESIGN

Retrospective analysis.

SETTING

Academic institution.

PATIENTS

: All patients <or=18 yrs old at our institution who received >or=24 hrs of fenoldopam therapy. Exclusion criteria included mechanical circulatory support, initiation of fenoldopam in the operating room, and age >18 yrs.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Demographics, renal function, fenoldopam dosing, concomitant inotropes, and inotrope score data were collected and analyzed. Thirteen patients (age 0.3-18.7 yrs, median 5.5 yrs) received a mean infusion dose of 0.07 +/- 0.08 microg/kg/min (range 0.01-0.26 microg/kg/min) over the first 24 hrs of therapy. Eight patients received fenoldopam to augment urine output, and five patients received fenoldopam to increase renal perfusion. Nine (69%) patients received dopamine concurrently. Mean inotrope score at the beginning of therapy was 11.3 +/- 7.6 and did not change during therapy. Mean urine output increased from 1.82 +/- 1.5 mL/kg/hr to 2.74 +/- 1.4 mL/kg/hr (p = .009) in the first 24 hrs of fenoldopam therapy. No change in serum creatinine occurred (p not significant). Blood urea nitrogen was significantly different from baseline (41.7 +/- 18.7 vs. 49.0 +/- 19.8 mg/dL, p = .02). Patients with lower baseline urine output had a greater increase in urine output with fenoldopam. One patient experienced clinically significant hypotension while receiving fenoldopam, which was thought to be due to a concurrent nitroprusside infusion.

CONCLUSIONS

Fenoldopam increases urine output in select critically ill pediatric patients without requiring escalation of inotropic support. There were no adverse hemodynamic effects or alterations in serum creatinine. Further prospective pediatric studies to define the role of fenoldopam in children are warranted.

Acute renal failure in critically ill surgical patients: persistent lethality despite new modes of renal replacement therapy

OBJECTIVE

Despite improved resuscitation and sepsis care, acute renal failure (ARF) remains common in critically ill surgical patients. New methods of renal replacement therapy (RRT) are being used in surgical intensive care units (SICUs), including high-flux hemodialysis (HD) and continuous RRT (CRRT). RRT is being used increasingly early in the course of ARF, but data are scant to suggest that mortality is improved. Consequently, we determined whether outcomes were improved with CRRT in SICU patients, and hypothesized that CRRT lowers mortality for patients with ARF.

METHODS

Patients who developed ARF (acute increase in serum creatinine concentration >or=2.4 mg/dL) in the SICU from 1993 to 2004 were identified. Data collected prospectively included year of admission, age, gender, Acute Physiology and Chronic Health Evaluation (APACHE) III score, cumulative multiple organ dysfunction score and its individual components, cumulative nonrenal organ dysfunction score, and need for RRT. Patients were stratified January 1994 to January 2001 (pre-CRRT) and February 2001 to December 2004 (post-CRRT). The primary endpoint was mortality.

RESULTS

Among 8,505 SICU patients, 530 (6.2%) developed ARF. Three hundred and eleven patients were treated pre-CRRT and 219 thereafter. Female patients comprised 35% of ARF patients. The mean age was 69 years +/- 2 years, and the mean APACHE III score was 81 +/- 1 point for ARF patients. HD was performed in 15.6% of ARF patients before 2001 and 5.5% of ARF patients in 2001 and thereafter. CRRT was performed in 20.1% of ARF patients in 2001 and thereafter. Overall mortality for ARF patients was 45% (APACHE III normative predicted mortality: 55%) with no difference over time (pre-CRRT = 46.3%, post-CRRT = 45.2%, p = 0.86). Patients who required RRT had a mean APACHE III score of 91 +/- 1 point, with 61% mortality (predicted mortality: 67%), with no difference over time. Independent predictors of mortality overall and for ARF patients included age and the magnitude of renal, cardiovascular, hepatic, and neurologic dysfunction. In comparison with CRRT, HD was associated with a decreased risk of death.

CONCLUSIONS

Despite more frequent RRT and the use of CRRT, the mortality of ARF in critically ill surgical patients remains high because of nonrenal organ dysfunction. Considering that ARF-related mortality was decreased by intermittent HD, and that intermittent RRT is less costly, patients who need RRT should be treated preferentially with HD.

A comparison of albumin-bolus therapy versus normal saline-bolus therapy for hypotension in neonates

OBJECTIVE

We compared responses to bolus infusion of 5% albumin (ALB) or normal saline (NS) for hypotension in neonates.

STUDY DESIGN

Hypotensive infants were given 10 ml kg(-1) of NS or ALB. A second bolus was given for persistent hypotension. Dopamine therapy was started for hypotension after the second bolus. The primary response was increase in arterial blood pressure toward normal range 1 h postinfusion. Secondary measures included duration of normotension, meeting criteria for second bolus, meeting criteria for vasopressor support and cost comparison.

RESULT

Those receiving ALB (N=49 ALB and 52 NS) were more likely to achieve a normotensive state (ALB=57.1%, NS=32.1% P=0.01) 1 h following the initial bolus therapy. Subsequently, the NS group was also more likely to qualify for vasopressor infusion (ALB=24.5%, NS=44.2% P=0.02). Overall cost for either therapy was equivalent.

CONCLUSION

In hypotensive neonates, ALB results in a greater likelihood of achieving normotension and decreased subsequent use of vasopressors when compared to NS.

The effects of dopamine on the respiratory system: Friend or foe?

Dopamine (DA) is an immediate precursor of noradrenaline that has stimulatory or inhibitory effects on a variety of adrenergic receptors. DA is primarily used in the management of circulatory shock for its combined vasopressor and inotropic effects, but it may also exert significant effects on the respiratory system Although the respiratory effects of intravenous DA attract less attention than its hemodynamic effects, there is evidence that DA affects ventilation, pulmonary circulation, bronchial diameter, neuromodulation of sensory pulmonary nerves and lung water clearance. Through these complex mechanisms, DA may exert beneficial as well as detrimental effects on respiration. DA may have beneficial effects on the respiratory system by decreasing oedema formation and improving respiratory muscle function, but can also have deleterious effects, by inhibiting ventilation. Hence, DA may be beneficial in lung oedema, but harmful in cases of difficult weaning from mechanical ventilation. DA should be used with caution in patients with heart failure during weaning from mechanical respiration; however, critically ill patients with chronic obstructive pulmonary disease (COPD) do not show this negative effect of DA on ventilatory drive.

[Is there still a place for dopamine in the paediatric critical care setting?]

Dopamine is mostly used in patients with cardiogenic or septic shock, but its place in critical care medicine is often questioned. Dopamine, of which pharmacology in children is variable, is prescribed for its inotropic effect, associated with an increase in cardiac output and at a lesser degree blood pressure. Beneficial effects (need for renal replacement therapy and mortality) of low dose in patients at risk of, or with acute renal failure are not demonstrated. Dopamine has numerous potential deleterious effects on local circulations (pulmonary, cerebral, coronary and cutaneous), respiratory function, gastroduodenal motility, endocrine function (further depression of the hypothalamic-pituitary axis induced by stress) and immunity (partially due to decreased production of prolactin). Finally, in shocked adults dopamine infusion might be associated with an increase in mortality rate. Dopamine remains the most prescribed catecholamine, either in adults or children. It still is one of the first line drug included in the recent recommendations for the treatment of septic shock (norepinephrine tends to replace it), cardiogenic shock (dobutamine is the first drug), severe head trauma, and organ donor in cerebral death. In conclusion, if dopamine is today less used, there is no proof that its deleterious effects are associated with an excess of mortality. Thus, dopamine still is part of the stock of drugs that act on the cardiocirculatory system (but for how long?).

Cardiovascular impact of dobutamine in neonates with myocardial dysfunction

OBJECTIVE

To study effects of dobutamine on cardiac functional parameters, cerebral, mesenteric and renal blood flow in preterm neonates with myocardial dysfunction.

STUDY DESIGN

Prospective evaluation of Doppler sonographically measured left ventricular systolic time intervals, stroke volume (SV), cardiac output (CO), and blood flow parameters of anterior cerebral artery (ACA), superior mesenteric artery (SMA) and renal arteries (RA), before, after 20 min and 8-10 h of dobutamine treatment in 20 neonates (gestational age 29.6+/-4.4 weeks, birth weight 1450+/-609 g and postnatal age 2+/-2.1 days). Dobutamine was given in a mean dosage of 9.1+/-1.1 microg/kg.

RESULTS

After 20 min SV increased from 1.71+/-0.5 ml to 2.12+0.57 ml/kg, CO from 223+/-76 to 290 ml/kg/min. A shortening of left ventricular pre ejection period from 86+/-12 to 66+/-13 ms and of the ratio of pre-ejection period/ejection time from 0.52+/-0.12 to 0.40+/-0.11 were observed. Blood flow velocities of ACA increased after 8-10 h: peak systolic flow velocity (PSV) from 19.0+/-6 to 29.6+/-7.1 ms, end diastolic velocity (EDV) from 2.9+/-2.6 to 12.7+/-11.3 ms. PSV of SMA increased from 32.5+/-4.7 to 49.7+/-7.8 ms after 8-10 h, EDV from 8.9+/-8 ms to 20.6+/-6.1 ms. PSV of RA increased from 18.2+/-6.1 ms to 39.9+/-4.8 ms, EDV from 2.2+/-1.2 to 8.2+/-2.1 ms after 8-10 h. The pulsatility indices decreased significantly after 8-10 h: ACA from 2.3+/-0.6 to 1.4+/-0.5, SMA from 1.7 to 1.2 and RA from 2.57 to 1.57.

CONCLUSION

Dobutamine improves the cardiac functional parameters already after 20 min and has an influence on the blood flow parameters of ACA, SMA and RA 8-10 h after administration in neonates with myocardial dysfunction.

Medical management to optimize donor organ potential: review of the literature

PURPOSE

Over the past two decades, the demand for donor organs continues to outpace the number of organs available for transplantation. Parallel with this has been a change in the demographics of organ donors with an increase in older donors and donors with marginal organs as a proportion of the total organ donor pool. Consequently, efforts have been made to improve the medical care delivered to potential organ donors to improve the conversion rate and graft survival of available organs. The purpose of this literature review is to provide updated recommendations for the contemporary management of organ donors after the neurological determination of death in order to maximize the probability of recipient graft survival.

SOURCES

A comprehensive review of the literature obtained through searches of MEDLINE/PubMed, and personal reference files.

PRINCIPAL FINDINGS

Contemporary management of the organ donor after neurological determination of death includes therapies to prevent the detrimental effects of the autonomic storm, the use of invasive hemodynamic monitoring and aggressive respiratory therapy including therapeutic bronchoscopy in marginal heart and lung donors, and the use of hormonal therapy including vasopressin, corticosteroids, triiodothyronine or thyroxine, and insulin for the pituitary failure and inflammation seen in brain dead organ donors. The importance of normalizing donor physiology to optimize all available organs is stressed.

CONCLUSION

Aggressive hemodynamic and respiratory management of solid organ donors, coupled with the use of hormonal therapy improves the rate of conversion and graft survival in solid organ recipients.

The dynamic neuroendocrine response to critical illness

The severity of striking alterations in the hypothalamic-anterior pituitary-peripheral hormone axes, which are the hallmark of severity of critical illness, is associated with a high risk for morbidity and mortality. Most attempts to correct the hormone balance are ineffective or harmful because of lack of pathophysiologic understanding. Extensive research has provided more insight in the biphasic neuroendocrine response to critical illness: the acute phase is characterized by an actively secreting pituitary but low peripheral effector hormone levels. In contrast, in prolonged critical illness, uniform suppression of the neuroendocrine axes, predominantly of hypothalamic origin, contributes to low serum levels of the respective target-organ hormones.

Changes within the thyroid axis during the course of critical illness

This article reviews the mechanisms behind the observed changes in plasma thyroid hormone levels in the acute phase and the prolonged phase of critical illness. It focuses on the neuroendocrinology of the low triiodothyronine syndrome and on thyroid hormone metabolism by deiodination and transport.

[Diagnosis and therapy of sepsis. Guidelines of the German Sepsis Society Inc. and the German Interdisciplinary Society for Intensive and Emergency Medicine]

A recent survey conducted by the publicly funded Competence Network Sepsis (SepNet) reveals that severe sepsis and/or septic shock occurs in 75,000 inhabitants (110 out of 100,000) and sepsis in 79,000 inhabitants (116 out of 100,000) in Germany annually. This illness is responsible for approximately 60,000 deaths and ranges as the third most frequent cause of death after acute myocardial infarction. Direct costs for the intensive care of patients with severe sepsis alone amount to approximately 1.77 billion euros, which means that about 30% of the budget in intensive care is used to treat severe sepsis. However, until now German guidelines for the diagnosis and therapy of severe sepsis did not exist. Therefore, the German Sepsis Society initiated the development of guidelines which are based on international recommendations by the International Sepsis Forum (ISF) and the Surviving Sepsis Campaign (SSC) and take into account the structure and organization of the German health care system. Priority was given to the following guideline topics: a) diagnosis, b) prevention, c) causative therapy, d) supportive therapy, e) adjunctive therapy. The guidelines development process was carefully planned and strictly adhered to the requirements of the Working Group of Scientific Medical Societies (AWMF).

Endocrine aspects of acute and prolonged critical illness

Critical illness is characterized by striking alterations in the hypothalamic-anterior-pituitary-peripheral-hormone axes, the severity of which is associated with a high risk of morbidity and mortality. Most attempts to correct hormone balance have been shown ineffective or even harmful because of a lack of pathophysiologic insight. There is a biphasic (neuro)endocrine response to critical illness. The acute phase is characterized by an actively secreting pituitary, but the concentrations of most peripheral effector hormones are low, partly due to the development of target-organ resistance. In contrast, in prolonged critical illness, uniform (predominantly hypothalamic) suppression of the (neuro)endocrine axes contributes to the low serum levels of the respective target-organ hormones. The adaptations in the acute phase are considered to be beneficial for short-term survival. In the chronic phase, however, the observed (neuro)endocrine alterations appear to contribute to the general wasting syndrome. With the exception of intensive insulin therapy, and perhaps hydrocortisone administration for a subgroup of patients, no hormonal intervention has proven to beneficially affect outcome. The combined administration of hypothalamic releasing factors does, however, hold promise as a safe therapy to reverse the (neuro)endocrine and metabolic abnormalities of prolonged critical illness by concomitant reactivation of the different anterior-pituitary axes.

A Comparison of Fenoldopam with Dopamine and Sodium Nitroprusside in Patients Undergoing Cross-Clamping of the Abdominal Aorta

Fenoldopam, a selective dopamine-1-receptor agonist, decreases arterial blood pressure rapidly, with a brief duration of action similar to sodium nitroprusside (SNP), but in contrast to SNP, it increases renal blood flow. We compared the hemodynamic and renal effects of fenoldopam in patients undergoing abdominal aortic surgery requiring cross-clamping of the aorta with another therapeutic option, dopamine and SNP. Fenoldopam or 2 mcg x kg(-1) x min(-1) of dopamine and SNP was infused before incision in 60 randomly selected patients in a double-blind fashion. Hemodynamic variables were recorded before incision, immediately before clamping the aorta, 5 min after cross-clamp release and upon completion of surgery. Urine output, serum creatinine, and creatinine clearance were measured intraoperatively and postoperatively. Characteristics were compared between groups using two-sample rank sum test for continuous variables and Fisher's exact test for discrete variables. The occurrence of severe hypotension, maximum systolic blood pressure, and need for additional antihypertensive drugs were not different between the groups. Most intraoperative hemodynamic variables and all indices of renal function did not differ according to treatment. Therefore, fenoldopam has no therapeutic advantage compared with similar therapies in patients undergoing major vascular surgery involving cross-clamping of the aorta.

Risk factors for death among critically ill patients with acute renal failure

CONTEXT AND OBJECTIVE

Acute renal failure is a common medical problem, with a high mortality rate. The aim of this work was to investigate the risk factors for death among critically ill patients with acute renal failure.

DESIGN AND SETTING

Retrospective cohort at the intensive care unit of Hospital Universitário Walter Cantídio, Fortaleza.

METHODS

Survivors and non-survivors were compared. Univariate and multivariate analyses were performed to establish risk factors for death.

RESULTS

Acute renal failure occurred in 128 patients (33.5%), with mean age of 49 +/- 20 years (79 males; 62%). Death occurred in 80 (62.5%). The risk factors most frequently associated with death were hypotension, sepsis, nephrotoxic drug use, respiratory insufficiency, liver failure, hypovolemia, septic shock, multiple organ dysfunction, need for vasoactive drugs, need for mechanical ventilation, oliguria, hypoalbuminemia, metabolic acidosis and anemia. There were negative correlations between death and: prothrombin time, hematocrit, hemoglobin, systolic blood pressure, diastolic blood pressure, arterial pH, arterial bicarbonate and urine volume. From multivariate analysis, the independent risk factors for death were: need for mechanical ventilation (OR = 3.15; p = 0.03), hypotension (OR = 3.48; p = 0.02), liver failure (OR = 5.37; p = 0.02), low arterial bicarbonate (OR = 0.85; p = 0.005), oliguria (OR = 3.36; p = 0.009), vasopressor use (OR = 4.83; p = 0.004) and sepsis (OR = 6.14; p = 0.003).

CONCLUSIONS

There are significant risk factors for death among patients with acute renal failure in intensive care units, which need to be identified at an early stage for early treatment.

An Overview of Inotropic Agents

The use of inotropic agents has been surrounded by many controversies. Recent guidelines for the treatment of patients with chronic and acute heart failure have elucidated some of the issues, but many remain. As a result, a substantial variability in the use of agents between institutions and caregivers remains, which mainly results from the lack of uniform data in the literature. Prospective randomized trials with a long-term follow-up and sufficient power are clearly needed, and a number of trials are currently in progress.

[Diagnosis and therapy of sepsis]

A recent survey conducted by the publicly funded Competence Network Sepsis (Sep- Net) reveals that severe sepsis and/or septic shock occurs in 75,000 inhabitants (110 out of 100,000) and sepsis in 79,000 inhabitants (116 out of 100,000) in Germany annually. This illness is responsible for approx. 60,000 deaths and ranges as the third most frequent cause of death after acute myocardial infarction. Direct costs for the intensive care of patients with severe sepsis alone amount to approx. 1.77 billion euros, which means that about 30% of the budget in intensive care is used to treat severe sepsis. However, until now German guidelines for the diagnosis and therapy of severe sepsis did not exist. Therefore, the German Sepsis Society initiated the development of guidelines which are based on international recommendations by the International Sepsis Forum (ISF) and the Surviving Sepsis Campaign (SSC) and take into account the structure and organisation of the German health care system. Priority was given to the following guideline topics: a) diagnosis, b) prevention, c) causative therapy, d) supportive therapy, e) adjunctive therapy. The guidelines development process was carefully planned and strictly adhered to according to the requirements of the Working Group of Scientific Medical Societies (AWMF).

Dopamine affects cellular immune functions during polymicrobial sepsis

OBJECTIVE

To determine whether infusion of dopamine modulates cellular immune functions and survival during systemic inflammation.

DESIGN AND SETTING

Randomized animal study, university research laboratory, Level I trauma center.

SUBJECTS

Male NMRI mice.

INTERVENTIONS

Mice were subjected to laparotomy (sham intervention, LAP) or polymicrobial sepsis induced by cecal ligation and puncture (CLP). Mice in each of these conditions received either an intraperitoneal infusion of 0.9% saline (CLP/saline; LAP/saline) or an intraperitoneal infusion of dopamine (1.0 microg/kg/min i.p., CLP/DOP; LAP/DOP). Metabolic data and survival were monitored 24 h and 48 h after onset of sepsis, and animals were terminated 48 h after induction of sepsis to determine splenocyte apoptosis (Annexin V binding capacity), splenocyte proliferation (3H-Thymidine incorporation assay), splenocyte IL-2, IL-6 and IFN-gamma release (ELISA) and leukocyte distribution (WBC; CD3, CD4, CD8, B220, F4/80, NK1.1).

MEASUREMENTS AND RESULTS

Infusion of dopamine in septic mice increased splenocyte apoptosis and decreased splenocyte proliferation and IL-2 release of septic mice. Furthermore, an inhibitory effect of dopamine infusion on splenocyte proliferation and the release of the TH1-cytokines IL-2 and IFN-gamma was observed in sham operated control mice. These effects were paralleled by a decreased survival of dopamine-treated septic animals (47% vs. 67%). Treatment with DOP did not affect sepsis-induced changes of leukocyte distribution.

CONCLUSIONS

We conclude that dopamine is capable of modulating cellular immune functions in a murine model of sepsis.