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Derry KH, Rocks MC, Izard P, Nicholas RS, Sommer PM, Hacquebord JH. Limb Necrosis in the Setting of Vasopressor Use. Am J Crit Care 2024; 33:226-233. [PMID: 38688844 DOI: 10.4037/ajcc2024171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
BACKGROUND It remains poorly understood why only some hemodynamically unstable patients who receive aggressive treatment with vasopressor medications develop limb necrosis. OBJECTIVE To determine the incidence of limb necrosis and the factors associated with it following high-dose vasopressor therapy. METHODS A retrospective case-control medical records review was performed of patients aged 18 to 89 years who received vasopressor therapy between 2012 and 2021 in a single academic medical center. The study population was stratified by the development of limb necrosis following vasopressor use. Patients who experienced necrosis were compared with age- and sex-matched controls who did not experience necrosis. Demographic information, comorbidities, and medication details were recorded. RESULTS The incidence of limb necrosis following vasopressor administration was 0.25%. Neither baseline demographics nor medical comorbidities differed significantly between groups. Necrosis was present in the same limb as the arterial catheter most often for femoral catheters. The vasopressor dose administered was significantly higher in the necrosis group than in the control group for ephedrine (P = .02) but not for the other agents. The duration of therapy was significantly longer in the necrosis group than in the control group for norepinephrine (P = .001), epinephrine (P = .04), and ephedrine (P = .01). The duration of vasopressin administration did not differ significantly between groups. CONCLUSION The findings of this study suggest that medication-specific factors, rather than patient and disease characteristics, should guide clinical management of necrosis in the setting of vasopressor administration.
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Affiliation(s)
- Kendall H Derry
- Kendall H. Derry is a resident physician, Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Madeline C Rocks
- Madeline C. Rocks is a medical student, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Paul Izard
- Paul Izard is a medical student, Harvard Medical School, Boston, Massachusetts
| | - Rebecca S Nicholas
- Rebecca S. Nicholas is an attending physician, Division of Hand Surgery, Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Philip M Sommer
- Philip M. Sommer is an attending physician, Perioperative Care and Pain Medicine Division, Department of Anesthesiology, NYU Langone Health, New York, New York
| | - Jacques H Hacquebord
- Jacques H. Hacquebord is an attending physician and chief, Division of Hand Surgery, Department of Orthopedic Surgery, Hansjorg Wyss Department of Plastic Surgery, NYU Langone Health, New York, New York
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Sanin GD, Cambronero GE, Wood EC, Patterson JW, Lane MR, Renaldo AC, Laingen BE, Rahbar E, Adams JY, Johnson A, Neff LP, Williams TK. MAN VERSUS MACHINE: PROVIDER DIRECTED VERSUS PRECISION AUTOMATED CRITICAL CARE MANAGEMENT IN A PORCINE MODEL OF DISTRIBUTIVE SHOCK. Shock 2024; 61:758-765. [PMID: 38526148 DOI: 10.1097/shk.0000000000002345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2024]
Abstract
ABSTRACT Background: Critical care management of shock is a labor-intensive process. Precision Automated Critical Care Management (PACC-MAN) is an automated closed-loop system incorporating physiologic and hemodynamic inputs to deliver interventions while avoiding excessive fluid or vasopressor administration. To understand PACC-MAN efficacy, we compared PACC-MAN to provider-directed management (PDM). We hypothesized that PACC-MAN would achieve equivalent resuscitation outcomes to PDM while maintaining normotension with lower fluid and vasopressor requirements. Methods : Twelve swine underwent 30% controlled hemorrhage over 30 min, followed by 45 min of aortic occlusion to generate a vasoplegic shock state, transfusion to euvolemia, and randomization to PACC-MAN or PDM for 4.25 h. Primary outcomes were total crystalloid volume, vasopressor administration, total time spent at hypotension (mean arterial blood pressure <60 mm Hg), and total number of interventions. Results : Weight-based fluid volumes were similar between PACC-MAN and PDM; median and IQR are reported (73.1 mL/kg [59.0-78.7] vs. 87.1 mL/kg [79.4-91.8], P = 0.07). There was no statistical difference in cumulative norepinephrine (PACC-MAN: 33.4 μg/kg [27.1-44.6] vs. PDM: 7.5 [3.3-24.2] μg/kg, P = 0.09). The median percentage of time spent at hypotension was equivalent (PACC-MAN: 6.2% [3.6-7.4] and PDM: 3.1% [1.3-6.6], P = 0.23). Urine outputs were similar between PACC-MAN and PDM (14.0 mL/kg vs. 21.5 mL/kg, P = 0.13). Conclusion : Automated resuscitation achieves equivalent resuscitation outcomes to direct human intervention in this shock model. This study provides the first translational experience with the PACC-MAN system versus PDM.
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Affiliation(s)
- Gloria D Sanin
- Department of General Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina
| | - Gabriel E Cambronero
- Department of General Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina
| | - Elizabeth C Wood
- Department of General Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina
| | - James W Patterson
- Department of Vascular and Endovascular Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina
| | - Magan R Lane
- Department of Vascular and Endovascular Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina
| | - Antonio C Renaldo
- Department of Biomedical Engineering, Wake Forest University School of Medicine, Winston Salem, North Carolina
| | - Bonnie E Laingen
- Department of General Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina
| | - Elaheh Rahbar
- Department of Biomedical Engineering, Wake Forest University School of Medicine, Winston Salem, North Carolina
| | - Jason Y Adams
- Department of Pulmonary, Critical Care, and Sleep Medicine, University of California, Davis, California
| | - Austin Johnson
- Department of Emergency Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Lucas P Neff
- Department of General Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina
| | - Timothy K Williams
- Department of Vascular and Endovascular Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina
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Hunter S, Manias E, Considine J. Nurse management of noradrenaline infusions in intensive care units: An observational study. Aust Crit Care 2024; 37:58-66. [PMID: 37940445 DOI: 10.1016/j.aucc.2023.09.009] [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: 03/14/2022] [Revised: 08/01/2023] [Accepted: 09/12/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND Intensive care nurse management of noradrenaline (norepinephrine) infusions is a common and essential clinical competency for patient haemodynamic support. Nurses titrate and wean noradrenaline infusions to a target blood pressure in a dynamic, high-risk, and unpredictable environment. Titration and weaning are complex interventions, and blood pressure goals are often variable. OBJECTIVES The aim was to examine how nurses used blood pressure targets when escalating, weaning, and titrating noradrenaline in intensive care patients admitted for haemodynamic management and explore patient blood pressure responses to changes in noradrenaline doses. METHODS In this naturalistic observational study, noradrenaline dose changes were classified as escalation, weaning, and titration changes and analysed to explore nursing practice. The study was undertaken in two adult medical/surgical intensive care units in Melbourne, Australia. Participants included intensive care nurses and patients who received noradrenaline infusions for haemodynamic support. RESULTS Observations of 14 nurse-patient dyads provided 25 h of blood pressure and noradrenaline dose data. Patient participants received weight-adjusted maximum noradrenaline doses of between 0.06 mcg/kg/min and 0.87 mcg/kg/minute, with those in the escalation group receiving dose increases of up to 5 mcg to achieve blood pressure goals. During weaning, patients maintained or increased their blood pressure as noradrenaline doses were decreased. Nurses consistently maintained blood pressures at higher than target goals, and despite constant fluctuations, they only documented blood pressure readings hourly. CONCLUSIONS Intensive care nurses managed noradrenaline to achieve mean arterial pressure targets that were variable and not evidence based. The disconnection between observed blood pressure fluctuations and nurse documentation of patient blood pressures was reflected in titration practices. Discrepancies between documented and actual blood pressures raised issues about data used by nurses and doctors to inform clinical practice on noradrenaline management.
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Affiliation(s)
- Stephanie Hunter
- Deakin University, School of Nursing and Midwifery, Centre for Quality and Patient Safety Research in the Institute for Health Transformation, 1 Gheringhap Street, Geelong 3220, Australia; Eastern Health Centre for Quality and Patient Safety Research - Eastern Health Partnership, 5 Arnold Street, Box Hill 3128, Victoria, Australia.
| | - Elizabeth Manias
- Deakin University, School of Nursing and Midwifery, Centre for Quality and Patient Safety Research in the Institute for Health Transformation, 1 Gheringhap Street, Geelong 3220, Australia
| | - Julie Considine
- Deakin University, School of Nursing and Midwifery, Centre for Quality and Patient Safety Research in the Institute for Health Transformation, 1 Gheringhap Street, Geelong 3220, Australia; Eastern Health Centre for Quality and Patient Safety Research - Eastern Health Partnership, 5 Arnold Street, Box Hill 3128, Victoria, Australia
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Hunter S, Considine J, Manias E. Nurse decision-making when managing noradrenaline in the intensive care unit: A naturalistic observational study. Intensive Crit Care Nurs 2023; 77:103429. [PMID: 37086603 DOI: 10.1016/j.iccn.2023.103429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 02/26/2023] [Accepted: 03/13/2023] [Indexed: 04/24/2023]
Abstract
OBJECTIVE Intensive care nurses care for critically ill patients in a complex, fast paced environment. Management of noradrenaline (norepinephrine) is core business for intensive care nurses and nurse decision-making on noradrenaline is poorly understood. The study objective was to investigate decision-making processes nurses use when caring for intensive care unit patients receiving noradrenaline. RESEARCH METHODOLOGY A qualitative exploratory design used the Cognitive Continuum Theory as a framework for naturalistic observations and interviews in two medical/surgical intensive care units in Melbourne, Australia. MAIN OUTCOME MEASURES Observational and interview data from field notes and audiovisual recordings were transcribed and coded to develop themes using reflexive thematic analysis. FINDINGS Fourteen nurse and patient dyads were recruited to observational sessions from December 2019 to June 2021. Three major themes developed were Learning through doing; Individualised patient care; and Clinical expertise, with six supporting sub-themes. Nurses learned to manage noradrenaline experientially and developed titration and weaning strategies to support decision-making. Blood pressure targets and monitor alarms were used consistently to aid decision-making processes. Nurses were observed practicing across the cognitive continuum depending on knowledge structure, complexity of interventions, response time, and patient acuity. CONCLUSION Experiential learning of complex and high-risk interventions in the absence of guidelines or algorithms meant nurses developed their own titration and weaning strategies based on constant evaluation and re-evaluation of patient cues. Patient heterogeneity, cue ambiguity and a dynamic practice environment contributed to decision-making complexity that would benefit from development of evidence-based practice resources. IMPLICATIONS FOR CLINICAL PRACTICE Nurses learn to manage noradrenaline through experiential learning, using blood pressure targets and monitor alarms to support decision-making when titrating and weaning noradrenaline. Nurses develop noradrenaline titration and weaning strategies to support decision-making in the absence of guidelines or algorithms. Supporting nurse decision-making and streamlining practice would reduce practice variation and cognitive workload.
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Affiliation(s)
- Stephanie Hunter
- Deakin University, School of Nursing and Midwifery, Centre for Quality and Patient Safety Research in the Institute for Health Transformation, 1 Gheringhap Street, Geelong 3220, Australia; Eastern Health Centre for Quality and Patient Safety Research - Eastern Health Partnership, 5 Arnold Street, Box Hill 3128, Victoria, Australia.
| | - Julie Considine
- Deakin University, School of Nursing and Midwifery, Centre for Quality and Patient Safety Research in the Institute for Health Transformation, 1 Gheringhap Street, Geelong 3220, Australia; Eastern Health Centre for Quality and Patient Safety Research - Eastern Health Partnership, 5 Arnold Street, Box Hill 3128, Victoria, Australia
| | - Elizabeth Manias
- Deakin University, School of Nursing and Midwifery, Centre for Quality and Patient Safety Research in the Institute for Health Transformation, 1 Gheringhap Street, Geelong 3220, Australia
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Richards-Belle A, Hylands M, Muttalib F, Taran S, Rochwerg B, Day A, Mouncey PR, Radermacher P, Couban R, Asfar P, Adhikari NKJ, Lamontagne F. Lower Versus Higher Exposure to Vasopressor Therapy in Vasodilatory Hypotension: A Systematic Review With Meta-Analysis. Crit Care Med 2023; 51:254-266. [PMID: 36398968 PMCID: PMC9848218 DOI: 10.1097/ccm.0000000000005736] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Balancing the risks of hypotension and vasopressor-associated adverse effects is a daily challenge in ICUs. We conducted a systematic review with meta-analysis to examine the effect of lower versus higher exposure to vasopressor therapy on mortality among adult ICU patients with vasodilatory hypotension. DATA SOURCES We searched Ovid Medline, Embase, and the Cochrane Central Register of Controlled Trials for studies published from inception to October 15, 2021. STUDY SELECTION We included randomized controlled trials of lower versus higher exposure to vasopressor therapy in adult ICU patients with vasodilatory hypotension without language or publication status limits. DATA EXTRACTION The primary outcome was 90-day all-cause mortality, with seven prespecified subgroups. Secondary outcomes included shorter- and longer-term mortality, use of life-sustaining therapies, vasopressor-related complications, neurologic outcome, and quality of life at longest reported follow-up. We conducted random-effects meta-analyses to calculate summary effect measures across individual studies (risk ratio [RR] for dichotomous variables, mean difference for continuous variables, both with 95% CIs). The certainty of the evidence was assessed using Grading of Recommendations, Assessment, Development, and Evaluation. We registered this review on the International Prospective Register of Systematic Reviews (CRD42021224434). DATA SYNTHESIS Of 3,403 records retrieved, 68 full-text articles were reviewed and three eligible studies included. Lower exposure to vasopressors probably lowers 90-day mortality but this is based on moderate-certainty evidence, lowered for imprecision (RR, 0.94; 95% CI, 0.87-1.02). There was no credible subgroup effect. Lower vasopressor exposure may also decrease the risk of supraventricular arrhythmia (odds ratio, 0.55; 95% CI, 0.36-0.86; low certainty). CONCLUSIONS In patients with vasodilatory hypotension who are started on vasopressors, moderate-certainty evidence from three randomized trials showed that lower vasopressor exposure probably lowers mortality. However, additional trial data are needed to reach an optimal information size to detect a clinically important 10% relative reduction in mortality with this approach.
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Affiliation(s)
- Alvin Richards-Belle
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | | | - Fiona Muttalib
- Center for Global Child Health, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Shaurya Taran
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada
| | - Bram Rochwerg
- Departments of Medicine, Critical Care Medicine, Pediatrics and Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Andrew Day
- Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, ON, Canada
| | - Paul R Mouncey
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | - Peter Radermacher
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum, Helmholtzstrasse 8-1, Ulm, Germany
| | - Rachel Couban
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Pierre Asfar
- Department of Medical Intensive Care, University Hospital of Angers, Angers, France
| | - Neill K J Adhikari
- Sunnybrook Health Sciences Centre and the University of Toronto, Toronto, ON, Canada
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Roberts RJ, Chen JT, Sevransky JE, Walkey AJ. Under Pressure: Do We "Dare Change Our Way of Caring" for Patients With Shock? Crit Care Med 2023; 51:326-328. [PMID: 36661458 DOI: 10.1097/ccm.0000000000005752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Russel J Roberts
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA
| | - Jen-Ting Chen
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, UCSF Medical Center, San Francisco, CA
| | - Jonathan E Sevransky
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Emory University Hospital, Atlanta GA
- Emory Critical Care Center, Emory Healthcare, Atlanta, GA
| | - Allan J Walkey
- Boston University School of Medicine and Boston Medical Center, Boston, MA
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Patel NTP, Goenaga-Diaz EJ, Lane MR, Austin Johnson M, Neff LP, Williams TK. Closed-loop automated critical care as proof-of-concept study for resuscitation in a swine model of ischemia-reperfusion injury. Intensive Care Med Exp 2022; 10:30. [PMID: 35799034 PMCID: PMC9263023 DOI: 10.1186/s40635-022-00459-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 06/27/2022] [Indexed: 12/05/2022] Open
Abstract
Background Volume expansion and vasopressors for the treatment of shock is an intensive process that requires frequent assessments and adjustments. Strict blood pressure goals in multiple physiologic states of shock (traumatic brain injury, sepsis, and hemorrhagic) have been associated with improved outcomes. The availability of continuous physiologic data is amenable to closed-loop automated critical care to improve goal-directed resuscitation. Methods Five adult swine were anesthetized and subjected to a controlled 30% estimated total blood volume hemorrhage followed by 30 min of complete supra-celiac aortic occlusion and then autotransfusion back to euvolemia with removal of aortic balloon. The animals underwent closed-loop critical care for 255 min after removal of the endovascular aortic balloon. The closed-loop critical care algorithm used proximal aortic pressure and central venous pressure as physiologic input data. The algorithm had the option to provide programmatic control of pumps for titration of vasopressors and weight-based crystalloid boluses (5 ml/kg) to maintain a mean arterial pressure between 60 and 70 mmHg. Results During the 255 min of critical care the animals experienced hypotension (< 60 mmHg) 15.3% (interquartile range: 8.6–16.9%), hypertension (> 70 mmHg) 7.7% (interquartile range: 6.7–9.4%), and normotension (60–70 mmHg) 76.9% (interquartile range: 76.5–81.2%) of the time. Excluding the first 60 min of the critical care phase the animals experienced hypotension 1.0% (interquartile range: 0.5–6.7%) of the time. Median intervention rate was 8.47 interventions per hour (interquartile range: 7.8–9.2 interventions per hour). The proportion of interventions was 61.5% (interquartile range: 61.1–66.7%) weight-based crystalloid boluses and 38.5% (interquartile range: 33.3–38.9%) titration of vasopressors. Conclusion This autonomous critical care platform uses critical care adjuncts in an ischemia–reperfusion injury model, utilizing goal-directed closed-loop critical care algorithm and device actuation. This description highlights the potential for this approach to deliver nuanced critical care in the ICU environment, thereby optimizing resuscitative efforts and expanding capabilities through cognitive offloading. Future efforts will focus on optimizing this platform through comparative studies of inputs, therapies, and comparison to manual critical care. Supplementary Information The online version contains supplementary material available at 10.1186/s40635-022-00459-2.
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Affiliation(s)
- Nathan T P Patel
- Department of Surgery, Wake Forest Baptist Medical Center, Hanes Building, B005, One Medical Center Boulevard, Winston-Salem, NC, 27157, USA.
| | - Eduardo J Goenaga-Diaz
- Division of Cardiac Anesthesiology, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Magan R Lane
- Department of Cardiothoracic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - M Austin Johnson
- Division of Emergency Medicine, University of Utah, Salt Lake City, UT, USA
| | - Lucas P Neff
- Department of Pediatric Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - Timothy K Williams
- Department of Vascular/Endovascular Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
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Mohseni S, Behnam-Roudsari S, Tarbiat M, Shaker P, Shivaie S, Shafiee MA. Perioperative Hypertension Etiologies in Patients Undergoing Noncardiac Surgery in University Health Network Hospitals–Canada from 2015–2020. Integr Blood Press Control 2022; 15:23-32. [PMID: 35340537 PMCID: PMC8942122 DOI: 10.2147/ibpc.s347395] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 03/03/2022] [Indexed: 12/04/2022] Open
Abstract
Introduction Perioperative hypertension, defined as increased blood pressure around the surgery, is a known risk factor for perioperative complications, including cardiovascular events. Identifying reasons associated with hypertension in each period is of great help in preventing and better managing perioperative hypertension. Objective The aim of the study was to explore common etiologies of hypertension during the perioperative period (pre, intra, and post-operation) in patients who underwent noncardiac surgeries in University Health Network (UHN) hospitals, Canada, from 2015 to 2020. Patients and Methods We retrospectively analyzed the medical records of 174 patients undergoing noncardiac surgeries who experienced perioperative hypertension. We assessed the prevalence of 10 reasons for perioperative hypertension as a whole and also each period separately according to the physicians’ notes in patients’ medical records. Two-way measurements ANOVA was used to determine the change of mean hypertension among patients for specific etiology. Results The common etiologies of perioperative hypertension were poorly controlled hypertension (21.8%), excessive fluid therapy (19.5%), excessive vasopressor (18.4%), and medication withdrawal (13.7%). Regarding each period separately, the most common reasons were poorly controlled hypertension for pre (42.9%) and intraoperative period (22.7%) and fluid overload for the postoperative period (20.1%). Poor control of hypertension showed both within-subject statistical significance for systolic and between-subject statistical significance for diastolic blood pressure. Conclusion Poorly controlled hypertension is the most significant etiology of perioperative hypertension in patients undergoing noncardiac surgeries. Apart from poorly controlled hypertension, as a patient-related factor, iatrogenic factors such as excessive vasopressor therapy, aggressive fluid replacement and poor management of antihypertensive medications can also cause perioperative hypertension.
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Affiliation(s)
- Sana Mohseni
- Division of General Internal Medicine, Department of Medicine, Toronto General Hospital, Toronto, ON M2G 2C4, Canada
| | - Sahar Behnam-Roudsari
- Division of General Internal Medicine, Department of Medicine, Toronto General Hospital, Toronto, ON M2G 2C4, Canada
| | - Mohammad Tarbiat
- Division of General Internal Medicine, Department of Medicine, Toronto General Hospital, Toronto, ON M2G 2C4, Canada
| | - Pouyan Shaker
- College of Medicine, Kansas City University, Kansas City, MO, USA
| | - Seyedmohammadshahab Shivaie
- Division of General Internal Medicine, Department of Medicine, Toronto General Hospital, Toronto, ON M2G 2C4, Canada
| | - Mohammad A Shafiee
- Division of General Internal Medicine, Department of Medicine, Toronto General Hospital, Toronto, ON M2G 2C4, Canada
- Correspondence: Mohammad A Shafiee, Division of General Internal Medicine, Department of Medicine, Toronto General Hospital, 200 Elizabeth Street, 14 EN-208, Toronto, ON M5G 2C4, Canada, Tel +1 416-340-4800 ext 6244, Fax +1 416-595-5826, Email
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Masse MH, Adhikari NKJ, Théroux X, Battista MC, D'Aragon F, Pinto R, Cohen A, Mayette M, St-Arnaud C, Kho M, Chassé M, Lebrasseur M, Watpool I, Porteous R, Wilcox ME, Lamontagne F. The evolution of mean arterial pressure in critically ill patients on vasopressors before and during a trial comparing a specific mean arterial pressure target to usual care. BMC Anesthesiol 2022; 22:6. [PMID: 34979938 PMCID: PMC8722048 DOI: 10.1186/s12871-021-01529-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 11/19/2021] [Indexed: 11/24/2022] Open
Abstract
Background In randomized clinical controlled trials, the choice of usual care as the comparator may be associated with better clinician uptake of the study protocol and lead to more generalizable results. However, if care processes evolve to resemble the intervention during the course of a trial, differences between the intervention group and usual care control group may narrow. We evaluated the effect on mean arterial pressure of an unblinded trial comparing a lower mean arterial pressure target to reduce vasopressor exposure, vs. a clinician-selected mean arterial pressure target, in critically ill patients at least 65 years old. Methods For this multicenter observational study using data collected both prospectively and retrospectively, patients were recruited from five of the seven trial sites. We compared the mean arterial pressure of patients receiving vasopressors, who met or would have met trial eligibility criteria, from two periods: [1] at least 1 month before the trial started, and [2] during the trial period and randomized to usual care, or not enrolled in the trial. Results We included 200 patients treated before and 229 after trial initiation. There were no differences in age (mean 74.5 vs. 75.2 years; p = 0.28), baseline Acute Physiology and Chronic Health Evaluation II score (median 26 vs. 26; p = 0.47) or history of chronic hypertension (n = 126 [63.0%] vs. n = 153 [66.8%]; p = 0.41). Mean of the mean arterial pressure was similar between the two periods (72.5 vs. 72.4 mmHg; p = 0.76). Conclusions The initiation of a trial of a prescribed lower mean arterial pressure target, compared to a usual clinician-selected target, was not associated with a change in mean arterial pressure, reflecting stability in the net effect of usual clinician practices over time. Comparing prior and concurrent control groups may alleviate concerns regarding drift in usual practices over the course of a trial or permit quantification of any change. Supplementary Information The online version contains supplementary material available at 10.1186/s12871-021-01529-w.
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Affiliation(s)
- Marie-Hélène Masse
- Faculty of Medicine and Health Sciences, Université de Sherbrooke, 12e Avenue Nord, Sherbrooke, Québec, J1H 5N4, Canada
| | - Neill K J Adhikari
- Interdepartmental Division of Critical Care Medicine, University of Toronto, 209 Victoria Street, Toronto, Ontario, M5B 1T8, Canada.,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, Ontario, M4N 3M5, Canada
| | - Xavier Théroux
- Faculty of Medicine and Health Sciences, Université de Sherbrooke, 12e Avenue Nord, Sherbrooke, Québec, J1H 5N4, Canada
| | - Marie-Claude Battista
- Faculty of Medicine and Health Sciences, Université de Sherbrooke, 12e Avenue Nord, Sherbrooke, Québec, J1H 5N4, Canada
| | - Frédérick D'Aragon
- Faculty of Medicine and Health Sciences, Université de Sherbrooke, 12e Avenue Nord, Sherbrooke, Québec, J1H 5N4, Canada
| | - Ruxandra Pinto
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, Ontario, M4N 3M5, Canada
| | - Alan Cohen
- Faculty of Medicine and Health Sciences, Université de Sherbrooke, 12e Avenue Nord, Sherbrooke, Québec, J1H 5N4, Canada
| | - Michaël Mayette
- Faculty of Medicine and Health Sciences, Université de Sherbrooke, 12e Avenue Nord, Sherbrooke, Québec, J1H 5N4, Canada
| | - Charles St-Arnaud
- Faculty of Medicine and Health Sciences, Université de Sherbrooke, 12e Avenue Nord, Sherbrooke, Québec, J1H 5N4, Canada
| | - Michelle Kho
- Faculty of Health Sciences, School of Rehabilitation Science, Institute of Applied Health Sciences, McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 4L8, Canada
| | - Michaël Chassé
- Department of Medicine, Université de Montréal, 2900 Boulevard Édouard-Montpetit, Montréal, Québec, H3T 1J4, Canada
| | - Martine Lebrasseur
- Centre de recherche, Centre hospitalier de l'Université de Montréal, 900 rue Saint-Denis, Montréal, Québec, H2X 0A9, Canada
| | - Irene Watpool
- Ottawa Hospital Research Institute, 1053 Carling Ave, Ottawa, Ontario, K1Y 4E9, Canada
| | - Rebecca Porteous
- Ottawa Hospital Research Institute, 1053 Carling Ave, Ottawa, Ontario, K1Y 4E9, Canada
| | - M Elizabeth Wilcox
- Interdepartmental Division of Critical Care Medicine, University of Toronto, 209 Victoria Street, Toronto, Ontario, M5B 1T8, Canada
| | - François Lamontagne
- Faculty of Medicine and Health Sciences, Université de Sherbrooke, 12e Avenue Nord, Sherbrooke, Québec, J1H 5N4, Canada.
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Lat I, Coopersmith CM, De Backer D. The Surviving Sepsis Campaign: Fluid Resuscitation and Vasopressor Therapy Research Priorities in Adult Patients. Crit Care Med 2021; 49:623-635. [PMID: 33731607 PMCID: PMC7963440 DOI: 10.1097/ccm.0000000000004864] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Expand upon the priorities of fluid resuscitation and vasopressor therapy research priorities identified by a group of experts assigned by the Society of Critical Care Medicine and the European Society of Intensive Care Medicine. DATA SOURCES Original article, literature search. STUDY SELECTION Several members of the original task force with expertise specific to the area of fluid resuscitation and vasopressor therapy. DATA EXTRACTION None. DATA SYNTHESIS None. CONCLUSION In the second of a series of manuscripts subsequent to the original article, members with expertise in the subjects expound upon the three identified priorities related to fluid resuscitation and vasopressor therapies. This analysis summarizes what is known and what were identified as ongoing and future research.
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Affiliation(s)
- Ishaq Lat
- Department of Pharmacy, Shirley Ryan AbilityLab, Chicago, IL
| | - Craig M Coopersmith
- Department of Surgery and Emory Critical Care Center, Emory University, Atlanta, GA
| | - Daniel De Backer
- Department of Intensive Care, Chirec Hospitals, Université Libre de Bruxelles, Brussels, Belgium
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11
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Lat I, Coopersmith CM, De Backer D, Coopersmith CM. The surviving sepsis campaign: fluid resuscitation and vasopressor therapy research priorities in adult patients. Intensive Care Med Exp 2021; 9:10. [PMID: 33644843 PMCID: PMC7917035 DOI: 10.1186/s40635-021-00369-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Objective To expand upon the priorities of fluid resuscitation and vasopressor therapy research priorities identified by a group of experts assigned by the Society of Critical Care Medicine and the European Society of Intensive Care Medicine. Data Sources Original paper and literature search. Study Selection Several members of the original task force with expertise specific to the area of fluid resuscitation and vasopressor therapy. Data Extraction None. Data Synthesis None. Conclusion In the second of a series of manuscripts subsequent to the original paper, members with expertise in the subjects expound upon the three identified priorities related to fluid resuscitation and vasopressor therapies. This analysis summarizes what is known and what were identified as ongoing and future research.
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Affiliation(s)
- Ishaq Lat
- Department of Pharmacy, Shirley Ryan Abilitylab, Chicago, IL, USA.
| | - Craig M Coopersmith
- Department of Surgery and Emory Critical Care Center, Emory University, Atlanta, GA, USA
| | - Daniel De Backer
- Department of Intensive Care, Chirec Hospitals, Université Libre de Bruxelles, Brussels, Belgium
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12
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Goradia S, Sardaneh AA, Narayan SW, Penm J, Patanwala AE. Vasopressor dose equivalence: A scoping review and suggested formula. J Crit Care 2021; 61:233-240. [DOI: 10.1016/j.jcrc.2020.11.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 10/26/2020] [Accepted: 11/10/2020] [Indexed: 12/20/2022]
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Mouncey PR, Richards-Belle A, Thomas K, Harrison DA, Sadique MZ, Grieve RD, Camsooksai J, Darnell R, Gordon AC, Henry D, Hudson N, Mason AJ, Saull M, Whitman C, Young JD, Lamontagne F, Rowan KM. Reduced exposure to vasopressors through permissive hypotension to reduce mortality in critically ill people aged 65 and over: the 65 RCT. Health Technol Assess 2021; 25:1-90. [PMID: 33648623 PMCID: PMC7957458 DOI: 10.3310/hta25140] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Vasopressors are administered to critical care patients to avoid hypotension, which is associated with myocardial injury, kidney injury and death. However, they work by causing vasoconstriction, which may reduce blood flow and cause other adverse effects. A mean arterial pressure target typically guides administration. An individual patient data meta-analysis (Lamontagne F, Day AG, Meade MO, Cook DJ, Guyatt GH, Hylands M, et al. Pooled analysis of higher versus lower blood pressure targets for vasopressor therapy septic and vasodilatory shock. Intensive Care Med 2018;44:12-21) suggested that greater exposure, through higher mean arterial pressure targets, may increase risk of death in older patients. OBJECTIVE To estimate the clinical effectiveness and cost-effectiveness of reduced vasopressor exposure through permissive hypotension (i.e. a lower mean arterial pressure target of 60-65 mmHg) in older critically ill patients. DESIGN A pragmatic, randomised clinical trial with integrated economic evaluation. SETTING Sixty-five NHS adult general critical care units. PARTICIPANTS Critically ill patients aged ≥ 65 years receiving vasopressors for vasodilatory hypotension. INTERVENTIONS Intervention - permissive hypotension (i.e. a mean arterial pressure target of 60-65 mmHg). Control (usual care) - a mean arterial pressure target at the treating clinician's discretion. MAIN OUTCOME MEASURES The primary clinical outcome was 90-day all-cause mortality. The primary cost-effectiveness outcome was 90-day incremental net monetary benefit. Secondary outcomes included receipt and duration of advanced respiratory and renal support, mortality at critical care and acute hospital discharge, and questionnaire assessment of cognitive decline and health-related quality of life at 90 days and 1 year. RESULTS Of 2600 patients randomised, 2463 (permissive hypotension, n = 1221; usual care, n = 1242) were analysed for the primary clinical outcome. Permissive hypotension resulted in lower exposure to vasopressors than usual care [mean duration 46.0 vs. 55.9 hours, difference -9.9 hours (95% confidence interval -14.3 to -5.5 hours); total noradrenaline-equivalent dose 31.5 mg vs. 44.3 mg, difference -12.8 mg (95% CI -18.0 mg to -17.6 mg)]. By 90 days, 500 (41.0%) patients in the permissive hypotension group and 544 (43.8%) patients in the usual-care group had died (absolute risk difference -2.85%, 95% confidence interval -6.75% to 1.05%; p = 0.154). Adjustment for prespecified baseline variables resulted in an odds ratio for 90-day mortality of 0.82 (95% confidence interval 0.68 to 0.98) favouring permissive hypotension. There were no significant differences in prespecified secondary outcomes or subgroups; however, patients with chronic hypertension showed a mortality difference favourable to permissive hypotension. At 90 days, permissive hypotension showed similar costs to usual care. However, with higher incremental life-years and quality-adjusted life-years in the permissive hypotension group, the incremental net monetary benefit was positive, but with high statistical uncertainty (£378, 95% confidence interval -£1347 to £2103). LIMITATIONS The intervention was unblinded, with risk of bias minimised through central allocation concealment and a primary outcome not subject to observer bias. The control group event rate was higher than anticipated. CONCLUSIONS In critically ill patients aged ≥ 65 years receiving vasopressors for vasodilatory hypotension, permissive hypotension did not significantly reduce 90-day mortality compared with usual care. The absolute treatment effect on 90-day mortality, based on 95% confidence intervals, was between a 6.8-percentage reduction and a 1.1-percentage increase in mortality. FUTURE WORK Future work should (1) update the individual patient data meta-analysis, (2) explore approaches for evaluating heterogeneity of treatment effect and (3) explore 65 trial conduct, including use of deferred consent, to inform future trials. TRIAL REGISTRATION Current Controlled Trials ISRCTN10580502. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 14. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Paul R Mouncey
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| | - Alvin Richards-Belle
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| | - Karen Thomas
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| | - David A Harrison
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| | - M Zia Sadique
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Richard D Grieve
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Julie Camsooksai
- Critical Care, Research and Innovation, Poole Hospital NHS Foundation Trust, Poole, UK
| | - Robert Darnell
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| | - Anthony C Gordon
- Division of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, London, UK
- Intensive Care Unit, Imperial College Healthcare NHS Trust, St Mary's Hospital, London, UK
| | | | - Nicholas Hudson
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| | - Alexina J Mason
- Division of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, London, UK
| | - Michelle Saull
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| | | | - J Duncan Young
- Kadoorie Centre for Critical Care Research and Education, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - François Lamontagne
- Department of Medicine, Université de Sherbrooke, Sherbrooke, QC, Canada
- Centre de Recherche du Centre Hospitalier, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Kathryn M Rowan
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
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14
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Masse MH, Battista MC, Wilcox ME, Pinto R, Marinoff N, D'Aragon F, St-Arnaud C, Mayette M, Leclair MA, Quiroz Martinez H, Grondin-Beaudoin B, Poulin Y, Carbonneau É, Seely AJE, Watpool I, Porteous R, Chassé M, Lebrasseur M, Lauzier F, Turgeon AF, Bellemare D, Mehta S, Charbonney E, Belley-Côté É, Botton É, Cohen D, Lamontagne F, Adhikari NKJ. Optimal VAsopressor TitraTION in patients 65 years and older (OVATION-65): protocol and statistical analysis plan for a randomised clinical trial. BMJ Open 2020; 10:e037947. [PMID: 33191251 PMCID: PMC7668371 DOI: 10.1136/bmjopen-2020-037947] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Vasodilatory hypotension is common among intensive care unit (ICU) patients; vasopressors are considered standard of care. However, optimal mean arterial pressure (MAP) targets for vasopressor titration are unknown. The objective of the Optimal VAsopressor TitraTION in patients 65 years and older (OVATION-65) trial is to ascertain the effect of permissive hypotension (vasopressor titration to achieve MAP 60-65 mm Hg) versus usual care on biomarkers of organ injury in hypotensive patients aged ≥65 years. METHODS AND ANALYSIS OVATION-65 is an allocation-concealed randomised trial in 7 Canadian hospitals. Eligible patients are ≥65 years of age, in an ICU with vasodilatory hypotension, receiving vasopressors for ≤12 hours to maintain MAP ≥65 mm Hg during or after adequate fluid resuscitation, and expected to receive vasopressors for ≥6 additional hours. Patients are excluded for any of the following: active treatment for spinal cord or acute brain injury; vasopressors given solely for bleeding, ventricular failure or postcardiopulmonary bypass vasoplegia; withdrawal of life-sustaining treatments expected within 48 hours; death perceived as imminent; previous enrolment in OVATION-65; organ transplant within the last year; receiving extracorporeal life support or lack of physician equipoise. Patients are randomised to permissive hypotension versus usual care for up to 28 days. The primary outcome is high-sensitivity troponin T, a biomarker of cardiac injury, on day 3. Secondary outcomes include biomarkers of injury to other organs (brain, liver, intestine, skeletal muscle); lactate (a biomarker of global tissue dysoxia); resource utilisation; adverse events; mortality (90 days and 6 months) and cognitive function (6 months). Assessors of biomarkers, mortality and cognitive function are blinded to allocation. ETHICS AND DISSEMINATION This protocol has been approved at all sites. Consent is obtained from the eligible patient, the substitute decision-maker if the patient is incapable, or in a deferred fashion where permitted. End-of-grant dissemination plans include presentations, publications and social media platforms and discussion forums. TRIAL REGISTRATION NUMBER NCT03431181.
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Affiliation(s)
- Marie-Hélène Masse
- Centre de recherche, Centre hospitalier universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Marie-Claude Battista
- Centre de recherche, Centre hospitalier universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
- Department of Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Mary Elizabeth Wilcox
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Ruxandra Pinto
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Nicole Marinoff
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Frédérick D'Aragon
- Centre de recherche, Centre hospitalier universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
- Department of Anesthesiology, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Charles St-Arnaud
- Centre de recherche, Centre hospitalier universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
- Department of Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Michael Mayette
- Centre de recherche, Centre hospitalier universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
- Department of Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Marc-André Leclair
- Department of Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | | | | | - Yannick Poulin
- Department of Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Élaine Carbonneau
- Centre de recherche, Centre hospitalier universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Andrew J E Seely
- Departments of Surgery and Critical Care Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Irene Watpool
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | | | - Michaël Chassé
- Department of Medicine, Université de Montréal, Montreal, Quebec, Canada
- Centre de recherche, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Martine Lebrasseur
- Centre de recherche, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - François Lauzier
- Population Health and Optimal Health Practices Research Unit, Centre de recherche du CHU de Québec-Université Laval, Quebec, Quebec, Canada
| | - Alexis F Turgeon
- Population Health and Optimal Health Practices Research Unit, Centre de recherche du CHU de Québec-Université Laval, Quebec, Quebec, Canada
| | - David Bellemare
- Population Health and Optimal Health Practices Research Unit, Centre de recherche du CHU de Québec-Université Laval, Quebec, Quebec, Canada
| | - Sangeeta Mehta
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Sinai Health System, Toronto, Ontario, Canada
| | - Emmanuel Charbonney
- Department of Medicine, Université de Montréal, Montreal, Quebec, Canada
- Centre de recherche, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Émilie Belley-Côté
- Department of Medicine, Division of Cardiology, McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, Hamilton, Ontario, Canada
| | | | - Dian Cohen
- Patient partners, Sherbrooke, Quebec, Canada
| | - François Lamontagne
- Centre de recherche, Centre hospitalier universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
- Department of Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Neill K J Adhikari
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine and Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
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15
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Gershengorn HB, Stelfox HT, Niven DJ, Wunsch H. Association of Premorbid Blood Pressure with Vasopressor Infusion Duration in Patients with Shock. Am J Respir Crit Care Med 2020; 202:91-99. [PMID: 32272020 DOI: 10.1164/rccm.201908-1681oc] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Rationale: Guidelines for vasopressor titration suggest a universal target-mean arterial pressure (MAP) >65 mm Hg. The implications for patients with premorbid low/high blood pressure are unknown.Objectives: To investigate the relationship between premorbid blood pressure and vasopressor duration for patients with shock.Methods: We performed a retrospective cohort study of adults admitted with shock to Calgary ICUs (June 2012-December 2018). The primary exposure was premorbid blood pressure: low (systolic <100); normal (systolic 100-139 and diastolic <90); and high (systolic ≥140 or diastolic ≥90). The primary outcome was vasopressor duration; secondary outcomes included ICU/hospital length of stay and ICU/hospital mortality. We examined associations of premorbid blood pressure with vasopressor duration and length of stay using multivariable competing risk models and mortality using multivariable mixed-effects logistic regression.Measurements and Main Results: Of 3,542 admissions with shock, 177 (5.0%) had premorbid low, 2,887 (81.5%) normal, and 478 (13.5%) high blood pressure. Premorbid low admissions had lower MAPs (vs. normal or high premorbid admissions) over the duration of vasopressor use (P = 0.003) and were maintained nearest premorbid MAPs while receiving vasopressors (P < 0.001). After adjustment, premorbid low admissions had longer vasopressor use (median, 1.35 d vs. 1.04 d for normal; hazard ratio for discontinuation vs. normal, 0.78 [0.73-0.85]; P < 0.001) and premorbid high admissions had shorter use (median, 0.84 d; hazard ratio, 1.22 [1.12-1.33]; P < 0.001). Premorbid low admissions had longer adjusted length of stay and higher adjusted mortality than premorbid normal admissions.Conclusions: Premorbid blood pressure was inversely associated with vasopressor duration.
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Affiliation(s)
- Hayley B Gershengorn
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Miami Miller School of Medicine, Miami, Florida.,Division of Critical Care Medicine, Albert Einstein College of Medicine, Bronx, New York
| | - Henry T Stelfox
- Department of Critical Care Medicine.,Department of Community Health Sciences, and.,O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Alberta Health Services, Edmonton, Alberta, Canada
| | - Daniel J Niven
- Department of Critical Care Medicine.,Department of Community Health Sciences, and.,O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Alberta Health Services, Edmonton, Alberta, Canada
| | - Hannah Wunsch
- Department of Critical Care Medicine, Sunnybrook Hospital, Toronto, Ontario, Canada; and.,Department of Anesthesiology and.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
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16
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Rinehart J, Lee S, Saugel B, Joosten A. Automated Blood Pressure Control. Semin Respir Crit Care Med 2020; 42:47-58. [PMID: 32746471 DOI: 10.1055/s-0040-1713083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Arterial pressure management is a crucial task in the operating room and intensive care unit. In high-risk surgical and in critically ill patients, sustained hypotension is managed with continuous infusion of vasopressor agents, which most commonly have direct α agonist activity like phenylephrine or norepinephrine. The current standard of care to guide vasopressor infusion is manual titration to an arterial pressure target range. This approach may be improved by using automated systems that titrate vasopressor infusions to maintain a target pressure. In this article, we review the evidence behind blood pressure management in the operating room and intensive care unit and discuss current and potential future applications of automated blood pressure control.
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Affiliation(s)
- Joseph Rinehart
- Department of Anesthesiology and Perioperative Care, University of California Irvine, Orange, California
| | - Sean Lee
- Department of Anesthesiology and Perioperative Care, University of California Irvine, Orange, California
| | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Outcomes Research Consortium, Cleveland, Ohio
| | - Alexandre Joosten
- Department of Anesthesiology, Erasme Hospital, Brussels, Belgium.,Department of Anesthesiology and Intensive Care, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, Université Paris-Saclay, Hôpital De Bicêtre, Assistance Publique Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre, France
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Automated Titration of Vasopressor Infusion Using a Closed-loop Controller: In Vivo Feasibility Study Using a Swine Model. Anesthesiology 2020; 130:394-403. [PMID: 30608239 DOI: 10.1097/aln.0000000000002581] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
WHAT WE ALREADY KNOW ABOUT THIS TOPIC Intraoperative hypotension has been associated with adverse postoperative outcomes.A randomized controlled trial of individualized blood pressure management in patients undergoing major abdominal surgery found reduced postoperative adverse events in patients in the blood pressure management intervention group versus the standard of care group. WHAT THIS ARTICLE TELLS US THAT IS NEW In this study of pigs with normovolemic hypotension induced by administration of sodium nitroprusside, an automated closed-loop vasopressor administration device was able to maintain mean arterial pressure within 5 mmHg of 80 mmHg for 98% of the intraoperative period. This suggests that norepinephrine can be accurately titrated using an automated infusion device in order to maintain target blood pressure. BACKGROUND Multiple studies have reported associations between intraoperative hypotension and adverse postoperative complications. One of the most common interventions in the management of hypotension is vasopressor administration. This approach requires careful and frequent vasopressor boluses and/or multiple adjustments of an infusion. The authors recently developed a closed-loop controller that titrates vasopressors to maintain mean arterial pressure (MAP) within set limits. Here, the authors assessed the feasibility and overall performance of this system in a swine model. The authors hypothesized that the closed-loop controller would be able to maintain MAP at a steady, predefined target level of 80 mmHg for greater than 85% of the time. METHODS The authors randomized 14 healthy anesthetized pigs either to a control group or a closed-loop group. Using infusions of sodium nitroprusside at doses between 65 and 130 µg/min, we induced four normovolemic hypotensive challenges of 30 min each. In the control group, nothing was done to correct hypotension. In the closed-loop group, the system automatically titrated norepinephrine doses to achieve a predetermined MAP of 80 mmHg. The primary objective was study time spent within ±5 mmHg of the MAP target. Secondary objectives were performance error, median performance error, median absolute performance error, wobble, and divergence. RESULTS The controller maintained MAP within ±5 mmHg of the target for 98 ± 1% (mean ± SD) of the time. In the control group, the MAP was 80 ± 5 mmHg for 14.0 ± 2.8% of the time (P< 0.0001). The MAP in the closed-loop group was above the target range for 1.2 ± 1.2% and below it for 0.5 ± 0.9% of the time. Performance error, median performance error, median absolute performance error, wobble, and divergence were all optimal. CONCLUSIONS In this experimental model of induced normovolemic hypotensive episodes in pigs, the automated controller titrated norepinephrine infusion to correct hypotension and keep MAP within ±5 mmHg of target for 98% of management time.
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18
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Lamontagne F, Richards-Belle A, Thomas K, Harrison DA, Sadique MZ, Grieve RD, Camsooksai J, Darnell R, Gordon AC, Henry D, Hudson N, Mason AJ, Saull M, Whitman C, Young JD, Rowan KM, Mouncey PR. Effect of Reduced Exposure to Vasopressors on 90-Day Mortality in Older Critically Ill Patients With Vasodilatory Hypotension: A Randomized Clinical Trial. JAMA 2020; 323:938-949. [PMID: 32049269 PMCID: PMC7064880 DOI: 10.1001/jama.2020.0930] [Citation(s) in RCA: 145] [Impact Index Per Article: 36.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 01/23/2020] [Indexed: 12/19/2022]
Abstract
Importance Vasopressors are commonly administered to intensive care unit (ICU) patients to raise blood pressure. Balancing risks and benefits of vasopressors is a challenge, particularly in older patients. Objective To determine whether reducing exposure to vasopressors through permissive hypotension (mean arterial pressure [MAP] target, 60-65 mm Hg) reduces mortality at 90 days in ICU patients aged 65 years or older with vasodilatory hypotension. Design, Setting, and Participants A multicenter, pragmatic, randomized clinical trial was conducted in 65 ICUs in the United Kingdom and included 2600 randomized patients aged 65 years or older with vasodilatory hypotension (assessed by treating clinician). The study was conducted from July 2017 to March 2019, and follow-up was completed in August 2019. Interventions Patients were randomized 1:1 to vasopressors guided either by MAP target (60-65 mm Hg, permissive hypotension) (n = 1291) or according to usual care (at the discretion of treating clinicians) (n = 1307). Main Outcome and Measures The primary clinical outcome was all-cause mortality at 90 days. Results Of 2600 randomized patients, after removal of those who declined or had withdrawn consent, 2463 (95%) were included in the analysis of the primary outcome (mean [SD] age 75 years [7 years]; 1387 [57%] men). Patients randomized to the permissive hypotension group had lower exposure to vasopressors compared with those in the usual care group (median duration 33 hours vs 38 hours; difference in medians, -5.0; 95% CI, -7.8 to -2.2 hours; total dose in norepinephrine equivalents median, 17.7 mg vs 26.4 mg; difference in medians, -8.7 mg; 95% CI, -12.8 to -4.6 mg). At 90 days, 500 of 1221 (41.0%) in the permissive hypotension compared with 544 of 1242 (43.8%) in the usual care group had died (absolute risk difference, -2.85%; 95% CI, -6.75 to 1.05; P = .15) (unadjusted relative risk, 0.93; 95% CI, 0.85-1.03). When adjusted for prespecified baseline variables, the odds ratio for 90-day mortality was 0.82 (95% CI, 0.68 to 0.98). Serious adverse events were reported for 79 patients (6.2%) in the permissive care group and 75 patients (5.8%) in the usual care group. The most common serious adverse events were acute renal failure (41 [3.2%] vs 33 [2.5%]) and supraventricular cardiac arrhythmia (12 [0.9%] vs 13 [1.0%]). Conclusions and Relevance Among patients 65 years or older receiving vasopressors for vasodilatory hypotension, permissive hypotension compared with usual care did not result in a statistically significant reduction in mortality at 90 days. However, the confidence interval around the point estimate for the primary outcome should be considered when interpreting the clinical importance of the study. Trial Registration isrctn.org Identifier: ISRCTN10580502.
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Affiliation(s)
- François Lamontagne
- Université de Sherbrooke, Sherbrooke, Quebec, Canada
- Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Alvin Richards-Belle
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, United Kingdom
| | - Karen Thomas
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, United Kingdom
| | - David A. Harrison
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, United Kingdom
| | - M. Zia Sadique
- London School of Hygiene and Tropical Medicine, Department of Health Services Research and Policy, London, United Kingdom
| | - Richard D. Grieve
- London School of Hygiene and Tropical Medicine, Department of Health Services Research and Policy, London, United Kingdom
| | - Julie Camsooksai
- Critical Care, Poole Hospital NHS Foundation Trust, Poole, Dorset, United Kingdom
| | - Robert Darnell
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, United Kingdom
| | - Anthony C. Gordon
- Division of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, London, United Kingdom
- Intensive Care Unit, Imperial College Healthcare NHS Trust, St Mary’s Hospital, Paddington, London, United Kingdom
| | | | - Nicholas Hudson
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, United Kingdom
| | - Alexina J. Mason
- London School of Hygiene and Tropical Medicine, Department of Health Services Research and Policy, London, United Kingdom
| | - Michelle Saull
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, United Kingdom
| | | | - J. Duncan Young
- Kadoorie Centre for Critical Care Research and Education, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom
| | - Kathryn M. Rowan
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, United Kingdom
| | - Paul R. Mouncey
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, United Kingdom
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Richards-Belle A, Mouncey PR, Grieve RD, Harrison DA, Sadique MZ, Henry D, Whitman C, Camsooksai J, Gordon AC, Young JD, Rowan KM, Lamontagne F. Evaluating the clinical and cost-effectiveness of permissive hypotension in critically ill patients aged 65 years or over with vasodilatory hypotension: Protocol for the 65 randomised clinical trial. J Intensive Care Soc 2019. [DOI: 10.1177/1751143719870088] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Vasodilatory shock is common in critically ill patients and vasopressors are a mainstay of therapy. A meta-analysis suggested that use of a higher, as opposed to a lower, mean arterial pressure target to guide titration of vasopressor therapy, could be associated with a higher risk of death in older critically ill patients. The 65 trial is a pragmatic, multi-centre, parallel-group, open-label, randomised clinical trial of permissive hypotension (a mean arterial pressure target of 60–65 mmHg during vasopressor therapy) versus usual care in critically ill patients aged 65 years or over with vasodilatory hypotension. The trial is conducted in 2600 patients from 65 United Kingdom adult, general critical care units. The primary outcome is all-cause mortality at 90 days. An economic evaluation is embedded. The 65 trial received favourable ethical opinion from the South Central – Oxford C Research Ethics Committee and approval from the Health Research Authority. The results will be presented at national and international conferences and published in peer-reviewed medical journals. Trial registration: ISRCTN10580502
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Affiliation(s)
- Alvin Richards-Belle
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, UK
| | - Paul R Mouncey
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, UK
| | - Richard D Grieve
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - David A Harrison
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, UK
| | - M Zia Sadique
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | | | | | - Julie Camsooksai
- Critical Care, Poole Hospital NHS Foundation Trust, Poole, Dorset, UK
| | - Anthony C Gordon
- Section of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, South Kensington Campus, London, UK
- Intensive Care Unit, Imperial College Healthcare NHS Trust, St Mary’s Hospital, Paddington, London, UK
| | - J Duncan Young
- Kadoorie Centre for Critical Care Research and Education, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Kathryn M Rowan
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, UK
| | - François Lamontagne
- Université de Sherbrooke, Sherbrooke, Quebec, Canada
- Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
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20
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Closed-loop hemodynamic management. Best Pract Res Clin Anaesthesiol 2019; 33:199-209. [PMID: 31582099 DOI: 10.1016/j.bpa.2019.04.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 04/23/2019] [Indexed: 12/11/2022]
Abstract
As the operating room and intensive care settings become increasingly complex, the required vigilance practitioners must dedicate to a wide array of clinical systems has increased concordantly. The resulting shortage of available attention to these various clinical tasks creates a vacuum for the introduction of systems that can administer well-established goal-directed therapies without significant provider feedback. Recently, there has been an explosion of academic exploration into creating such automated systems, with a strong specific focus on hemodynamic control. Within this field, the largest focus has been on goal-directed fluid therapy as systems automating vasopressor administration have only recently become viable options. Our goal in this review article is to summarize the validity of the relevant goal-directed hemodynamic systems and explore the expanding role of automation within these systems.
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21
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Scheeren TWL, Bakker J, De Backer D, Annane D, Asfar P, Boerma EC, Cecconi M, Dubin A, Dünser MW, Duranteau J, Gordon AC, Hamzaoui O, Hernández G, Leone M, Levy B, Martin C, Mebazaa A, Monnet X, Morelli A, Payen D, Pearse R, Pinsky MR, Radermacher P, Reuter D, Saugel B, Sakr Y, Singer M, Squara P, Vieillard-Baron A, Vignon P, Vistisen ST, van der Horst ICC, Vincent JL, Teboul JL. Current use of vasopressors in septic shock. Ann Intensive Care 2019; 9:20. [PMID: 30701448 PMCID: PMC6353977 DOI: 10.1186/s13613-019-0498-7] [Citation(s) in RCA: 94] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 01/22/2019] [Indexed: 12/29/2022] Open
Abstract
Background Vasopressors are commonly applied to restore and maintain blood pressure in patients with sepsis. We aimed to evaluate the current practice and therapeutic goals regarding vasopressor use in septic shock as a basis for future studies and to provide some recommendations on their use. Methods From November 2016 to April 2017, an anonymous web-based survey on the use of vasoactive drugs was accessible to members of the European Society of Intensive Care Medicine (ESICM). A total of 17 questions focused on the profile of respondents, triggering factors, first choice agent, dosing, timing, targets, additional treatments, and effects of vasopressors. We investigated whether the answers complied with current guidelines. In addition, a group of 34 international ESICM experts was asked to formulate recommendations for the use of vasopressors based on 6 questions with sub-questions (total 14). Results A total of 839 physicians from 82 countries (65% main specialty/activity intensive care) responded. The main trigger for vasopressor use was an insufficient mean arterial pressure (MAP) response to initial fluid resuscitation (83%). The first-line vasopressor was norepinephrine (97%), targeting predominantly a MAP > 60–65 mmHg (70%), with higher targets in patients with chronic arterial hypertension (79%). The experts agreed on 10 recommendations, 9 of which were based on unanimous or strong (≥ 80%) agreement. They recommended not to delay vasopressor treatment until fluid resuscitation is completed but rather to start with norepinephrine early to achieve a target MAP of ≥ 65 mmHg. Conclusion Reported vasopressor use in septic shock is compliant with contemporary guidelines. Future studies should focus on individualized treatment targets including earlier use of vasopressors.
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Affiliation(s)
- Thomas W L Scheeren
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, P.O. Box 30.001, 9700RB, Groningen, The Netherlands.
| | - Jan Bakker
- New York University Medical Center, New York, USA.,Columbia University Medical Center, New York, USA.,Erasmus MC University Medical Center, Rotterdam, Netherlands.,Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Daniel De Backer
- Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| | - Djillali Annane
- Department of Intensive Care Medicine, School of Medicine Simone Veil, Raymond Poincaré Hospital (APHP), University of Versailles-University Paris Saclay, 104 boulevard Raymond Poincaré, 92380, Garches, France
| | - Pierre Asfar
- Département de Médecine Intensive-Réanimation et de Médecine Hyperbare, Centre Hospitalier Universitaire Angers, Institut MITOVASC, CNRS, UMR 6214, INSERM U1083, Angers University, Angers, France
| | - E Christiaan Boerma
- Department of Intensive Care, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
| | - Maurizio Cecconi
- Department of Anaesthesia and Intensive Care Units, Humanitas Research Hospital and Humanitas University, Milan, Italy
| | - Arnaldo Dubin
- Cátedra de Farmacología Aplicada, Facultad de Ciencias Médicas, Universidad Nacional de La Plata y Servicio de Terapia Intensiva, Sanatorio Otamendi, Buenos Aires, Argentina
| | - Martin W Dünser
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University Linz, Linz, Austria
| | - Jacques Duranteau
- Assistance Publique des Hopitaux de Paris, Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, Hôpital de Bicêtre, Le Kremlin-Bicêtre, France
| | - Anthony C Gordon
- Section of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, London, UK
| | - Olfa Hamzaoui
- Assistance Publique-Hôpitaux de Paris Paris-Sud University Hospitals, Intensive Care Unit, Antoine Béclère Hospital, Clamart, France
| | - Glenn Hernández
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Marc Leone
- Assistance Publique Hôpitaux de Marseille, Service d'Anesthésie et de Réanimation CHU Nord, Aix Marseille Université, Marseille, France
| | - Bruno Levy
- Service de Réanimation Médicale Brabois et pôle cardio-médico-chirurgical, CHRU, INSERM U1116, Université de Lorraine, Brabois, 54500, Vandoeuvre les Nancy, France
| | - Claude Martin
- Assistance Publique Hôpitaux de Marseille, Service d'Anesthésie et de Réanimation CHU Nord, Aix Marseille Université, Marseille, France
| | - Alexandre Mebazaa
- Department of Anesthesia, Burn and Critical Care, APHP Hôpitaux Universitaires Saint Louis Lariboisière, U942 Inserm, Université Paris Diderot, Paris, France
| | - Xavier Monnet
- Assistance Publique-Hôpitaux de Paris, Paris-Sud University Hospitals, Medical Intensive Care Unit, Bicêtre Hospital, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Paris-Saclay University, Le Plessis-Robinson, France
| | - Andrea Morelli
- Department of Cardiovascular, Respiratory, Nephrological, Anesthesiological and Geriatric Sciences, University of Rome "La Sapienza", Rome, Italy
| | - Didier Payen
- INSERM 1160 and Hôpital Lariboisière, APHP, University Paris 7 Denis Diderot, Paris, France
| | | | - Michael R Pinsky
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, USA
| | - Peter Radermacher
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum, Ulm, Germany
| | - Daniel Reuter
- Department of Anesthesiology and Intensive Care Medicine, Rostock University Medical Centre, Rostock, Germany
| | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Yasser Sakr
- Department of Anesthesiology and Intensive Care, Uniklinikum Jena, Jena, Germany
| | - Mervyn Singer
- Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, London, UK
| | - Pierre Squara
- ICU Department, Réanimation CERIC, Clinique Ambroise Paré, Neuilly, France
| | - Antoine Vieillard-Baron
- Assistance Publique-Hôpitaux de Paris, Intensive Care Unit, University Hospital Ambroise Paré, Boulogne-Billancourt, France.,INSERM U-1018, CESP, Team 5, University of Versailles Saint-Quentin en Yvelines, Villejuif, France
| | - Philippe Vignon
- Medical-Surgical Intensive Care Unit, INSERM CIC-1435, Teaching Hospital of Limoges, University of Limoges, Limoges, France
| | - Simon T Vistisen
- Institute of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Iwan C C van der Horst
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Hanzeplein 1, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jean-Louis Teboul
- Service de Réanimation Médicale, Hôpital de Bicêtre, Hôpitaux Universitaires Paris-Sud, Le Kremlin-Bicêtre, France
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22
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Rinehart J, Joosten A, Ma M, Calderon MD, Cannesson M. Closed-loop vasopressor control: in-silico study of robustness against pharmacodynamic variability. J Clin Monit Comput 2018; 33:795-802. [PMID: 30539349 DOI: 10.1007/s10877-018-0234-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 12/06/2018] [Indexed: 12/28/2022]
Abstract
Initial feasibility of a novel closed-loop controller created by our group for closed-loop control of vasopressor infusions has been previously described. In clinical practice, vasopressor potency may be affected by a variety of factors including other pharmacologic agents, organ dysfunction, and vasoplegic states. The purpose of this study was therefore to evaluate the effectiveness of our controller in the face of large variations in drug potency, where 'effective' was defined as convergence on target pressure over time. We hypothesized that the controller would remain effective in the face up to a tenfold variability in drug response. To perform the robustness study, our physiologic simulator was used to create randomized simulated septic patients. 250 simulated patients were managed by the closed-loop in each of 7 norepinephrine responsiveness conditions: 0.1 ×, 0.2 ×, 0.5 ×, 1 ×, 2 ×, 5 ×, and 10 × expected population response to drug dose. Controller performance was evaluated for each level of norepinephrine response using Varvel's criteria as well as time-out-of-target. Median performance error and median absolute performance error were less than 5% in all response levels. Wobble was below 3% and divergence remained negative (i.e. the controller tended to converge towards the target over time) in all norepinephrine response levels, but at the highest response level of 10 × the value approached zero, suggesting the controller may be approaching instability. Response levels of 0.1 × and 0.2 × exhibited significantly higher time-out-of-target in the lower ranges (p < 0.001) compared to the 1 × response level as the controller was slower to correct the initial hypotension. In this simulation study, the closed-loop vasopressor controller remained effective in simulated patients exhibiting 0.1 to 10 × the expected population drug response.
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Affiliation(s)
- Joseph Rinehart
- Department of Anesthesiology & Perioperative Care, University of California Irvine, 101 The City Drive South, Orange, CA, 92868, USA.
| | - Alexandre Joosten
- Department of Anesthesiology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium.,Anesthesia and Intensive Care Department, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, Université Paris-Saclay, Hôpital De Bicêtre, Assistance Publique Hôpitaux de Paris (APHP), 78, Rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France
| | - Michael Ma
- Department of Anesthesiology & Perioperative Care, University of California Irvine, 101 The City Drive South, Orange, CA, 92868, USA
| | - Michael-David Calderon
- Department of Anesthesiology & Perioperative Care, University of California Irvine, 101 The City Drive South, Orange, CA, 92868, USA
| | - Maxime Cannesson
- Department of Anesthesiology and Perioperative Medicine, Davide Geffen School of Medicine, University of California Los Angeles UCLA, Los Angeles, CA, USA
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23
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Blood pressure variability in surgical and intensive care patients: Is there a potential for closed-loop vasopressor administration? Anaesth Crit Care Pain Med 2018; 38:69-71. [PMID: 30513357 DOI: 10.1016/j.accpm.2018.11.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 11/23/2018] [Accepted: 11/23/2018] [Indexed: 02/03/2023]
Abstract
Blood pressure management in the operating rooms (OR) and intensive care units (ICU) frequently involves manually titrated vasopressor therapy to an optimal range of mean arterial pressure (MAP). Ideally, changes in vasopressor infusion rates have to quickly follow variations in blood pressure measurements. However, such a tightly controlled feedback loop is difficult to achieve. Few studies have examined blood pressure control when vasopressor therapy is administered manually in OR and ICU patients. We extracted MAP data from 3623 patients (2530 from the ORs and 1093 from the ICU) on vasopressors from our electronic medical records. Coefficient of variation (= standard deviation/mean value) *100) was calculated and the values were additionally categorized into different MAP ranges (MAP < 60 mmHg, 60 < MAP < 80 and MAP > 80 mmHg). There was no statistically significant difference between both centres for MAP across all time points (80 ± 12 vs. 80 ± 16, P = 0.996, 95% CI -6 to 6). The coefficients of variation of MAP were 13.7 ± 5.4% and 18.4 ± 9.8% in the OR and in ICU respectively. Patients on vasopressors spent 48.8% treatment time with a MAP between 60 and 80 mmHg (11.2% time with MAP < 60 mmHg, and 40% with MAP > 80 mmHg). These results provide a reasonable baseline from which to establish whether 'reduced variability' may be achieved with a closed-loop vasopressor administration system.
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24
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Permissive hypotension during shock resuscitation: equipoise in all patients? Intensive Care Med 2017; 44:87-90. [PMID: 28551721 DOI: 10.1007/s00134-017-4849-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 05/22/2017] [Indexed: 12/19/2022]
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25
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A systematic review of vasopressor blood pressure targets in critically ill adults with hypotension. Can J Anaesth 2017; 64:703-715. [PMID: 28497426 DOI: 10.1007/s12630-017-0877-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Revised: 03/13/2017] [Accepted: 04/11/2017] [Indexed: 10/19/2022] Open
Abstract
PURPOSE Clinicians must balance the risks from hypotension with the potential adverse effects of vasopressors. Experts have recommended a mean arterial pressure (MAP) target of at least 65 mmHg, and higher in older patients and in patients with chronic hypertension or atherosclerosis. We conducted a systematic review of randomized-controlled trials comparing higher vs lower blood pressure targets for vasopressor therapy administered to hypotensive critically ill patients. METHODS We searched MEDLINE®, EMBASE™, and the Cochrane Central Register of Controlled Trials for studies of higher vs lower blood pressure targets for vasopressor therapy in critically ill hypotensive adult patients. Two reviewers independently assessed trial eligibility based on titles and abstracts, and they then selected full-text reports. Outcomes, subgroups, and analyses were prespecified. We used GRADE (Grading of Recommendations Assessment, Development and Evaluation) to rate the overall confidence in the estimates of intervention effects. RESULTS Of 8001 citations, we retrieved 57 full-text articles and ultimately included two randomized-controlled trials (894 patients). Higher blood pressure targets were not associated with lower mortality (relative risk [RR], 1.05; 95% confidence interval [CI], 0.90 to 1.23; P = 0.54), and neither age (P = 0.17) nor chronic hypertension (P = 0.32) modified the overall effect. Nevertheless, higher blood pressure targets were associated with a greater risk of new-onset supraventricular cardiac arrhythmia (RR, 2.08; 95% CI, 1.28 to 3.38; P < 0.01). CONCLUSION Current evidence does not support a MAP target > 70 mmHg in hypotensive critically ill adult patients requiring vasopressor therapy.
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