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Shea MG, Balaji L, Grossestreuer AV, Issa MS, Silverman J, Li F, Donnino MW, Berg KM. Oxygen metabolism after cardiac arrest: Patterns and associations with survival. Resusc Plus 2024; 19:100667. [PMID: 38827271 PMCID: PMC11143887 DOI: 10.1016/j.resplu.2024.100667] [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: 03/04/2024] [Revised: 04/30/2024] [Accepted: 05/13/2024] [Indexed: 06/04/2024] Open
Abstract
Aim Whether changes in oxygen metabolism, as measured by oxygen consumption (VO2), carbon dioxide production (VCO2) and the respiratory exchange ratio (RER), are associated with survival after cardiac arrest is poorly understood. In this prospective observational study, we investigated the association between VO2, VCO2, and RER in the initial 12 and 24 h after return of spontaneous circulation (ROSC) and survival to hospital discharge. Methods Adults with ROSC after cardiac arrest, admitted to the intensive care unit, requiring mechanical ventilation and treated with targeted temperature management were included. VO2 and VCO2 were measured continuously for 24 h after ROSC, using a noninvasive anesthesia monitor. Area under the curve for VO2, VCO2 & RER was calculated using all available values over 12 and 24 h after ROSC. Using logistic regression, we evaluated the relationship between these metabolic variables and survival to hospital discharge. Analyses were adjusted for temperature, vasopressors, and neuromuscular blockade. Results Sixty four patients were included. Mean age was 64 ± 16 years, and 59% were women. There was no significant association between the area under the curve of VO2 or VCO2 and survival. A higher RER in the initial 12 h was associated with better survival (aOR = 3.97, 95% CI [1.01,15.6], p = 0.048). Survival was lower in those with median RER < 0.7 in the initial 12 h compared with those with a median RER ≥ 0.7 (25% vs 67%, p = 0.011). Conclusion Higher RER in the initial 12 h was associated with survival after cardiac arrest. The etiology of unusually low RERs in this patient population remains unclear.
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Affiliation(s)
- Meredith G. Shea
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, 1 Deaconess Road, Rosenberg 2, Boston, MA 02215, USA
| | - Lakshman Balaji
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, 1 Deaconess Road, Rosenberg 2, Boston, MA 02215, USA
| | - Anne V. Grossestreuer
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, 1 Deaconess Road, Rosenberg 2, Boston, MA 02215, USA
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, 1 Deaconess Road, Rosenberg 2, Boston, MA 02215, USA
| | - Mahmoud S. Issa
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, 1 Deaconess Road, Rosenberg 2, Boston, MA 02215, USA
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, 1 Deaconess Road, Rosenberg 2, Boston, MA 02215, USA
| | - Jeremy Silverman
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, 1 Deaconess Road, Rosenberg 2, Boston, MA 02215, USA
| | - Franklin Li
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, 1 Deaconess Road, Rosenberg 2, Boston, MA 02215, USA
| | - Michael W. Donnino
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, 1 Deaconess Road, Rosenberg 2, Boston, MA 02215, USA
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, 1 Deaconess Road, Rosenberg 2, Boston, MA 02215, USA
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, 1 Deaconess Road, Rosenberg 2, Boston, MA 02215, USA
| | - Katherine M. Berg
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, 1 Deaconess Road, Rosenberg 2, Boston, MA 02215, USA
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, 1 Deaconess Road, Rosenberg 2, Boston, MA 02215, USA
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The Effect of a Single Dose of Thiamine on Oxygen Consumption in Patients Requiring Mechanical Ventilation for Acute Illness: A Phase II, Randomized, Double-Blind, Placebo-Controlled Trial. Crit Care Explor 2021; 3:e0579. [PMID: 34806022 PMCID: PMC8601368 DOI: 10.1097/cce.0000000000000579] [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] [Indexed: 11/26/2022] Open
Abstract
Lower oxygen consumption is associated with worse survival in septic shock and in other forms of critical illness. No treatment that increases oxygen extraction, a key determinant of oxygen consumption, has been found. Thiamine is required for aerobic metabolism, and deficiency is common in the critically ill. OBJECTIVES We evaluated the effect of thiamine on oxygen consumption in patients requiring mechanical ventilation for an acute illness. DESIGN Phase II, randomized, double-blind, and placebo-controlled trial. SETTING AND PARTICIPANTS ICUs in a tertiary care hospital in the United States. Patients admitted to the ICU and requiring mechanical ventilation were screened for enrollment. INTERVENTIONS After enrollment, baseline measurement of oxygen consumption and baseline laboratories including lactate, central venous oxygen saturation, and pyruvate dehydrogenase, a single dose of 200 mg IV thiamine or placebo was administered. Oxygen consumption was then monitored for 6 additional hours and repeat laboratories were drawn at the end of the protocol. MAIN OUTCOMES AND MEASURES The primary outcome was the change in oxygen consumption. Analysis was done using linear regression with a first-order autoregressive variance-covariance structure to account for repeated measures within subjects. Secondary outcomes included change in lactate, central venous oxygen saturation, and pyruvate dehydrogenase quantity and activity. RESULTS Sixty-seven patients were enrolled. After excluding 11 patients due to inadequate quantity or quality of oxygen consumption data, 56 patients were included. There was no difference in change in oxygen consumption in the 6 hours after study drug. Results for secondary outcomes were similarly negative. In the prespecified subgroup of 18 thiamine deficient patients, there was a difference in the two oxygen consumption curves (p = 0.006), although no difference in median oxygen consumption or area under the curve. CONCLUSIONS AND RELEVANCE A single dose of IV thiamine did not alter oxygen consumption in patients requiring mechanical ventilation for acute illness.
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Preliminary observations in systemic oxygen consumption during targeted temperature management after cardiac arrest. Resuscitation 2018; 127:89-94. [PMID: 29626611 DOI: 10.1016/j.resuscitation.2018.04.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 03/13/2018] [Accepted: 04/02/2018] [Indexed: 12/27/2022]
Abstract
AIM Limited data suggests low oxygen consumption (VO2), driven by mitochondrial injury, is associated with mortality after cardiac arrest. Due to the challenges of measurement in the critically ill, post-arrest metabolism remains poorly characterized. We monitored VO2, carbon dioxide production (VCO2) and the respiratory quotient (RQ) in post-arrest patients and explored associations with outcome. METHODS Using a gas exchange monitor, we measured continuous VO2 and VCO2 in post- arrest patients treated with targeted temperature management. We used area under the curve and medians over time to evaluate the association between VO2, VCO2, RQ and the VO2:lactate ratio with survival. RESULTS In 17 patients, VO2 in the first 12 h after return of spontaneous circulation (ROSC) was associated with survival (median in survivors 3.35 mL/kg/min [2.98,3.88] vs. non-survivors 2.61 mL/kg/min [2.21,2.94], p = .039). This did not persist over 24 h. The VO2:lactate ratio was associated with survival (median in survivors 1.4 [IQR: 1.1,1.7] vs. non-survivors 0.8 [IQR: 0.6,1.2] p < 0.001). Median RQ was 0.66 (IQR 0.63,0.70) and 71% of RQ measurements were <0.7. Patients with initial RQ < 0.7 had 17% survival versus 64% with initial RQ > 0.7 (p = .131). VCO2 was not associated with survival. CONCLUSIONS There was a significant association between VO2 and mortality in the first 12 h after ROSC, but not over 24 h. Lower VO2: lactate ratio was associated with mortality. A large percentage of patients had RQs below physiologic norms. Further research is needed to explore whether these parameters could have true prognostic value or be a potential treatment target.
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O'Driscoll BR, Howard LS, Earis J, Mak V. BTS guideline for oxygen use in adults in healthcare and emergency settings. Thorax 2017; 72:ii1-ii90. [DOI: 10.1136/thoraxjnl-2016-209729] [Citation(s) in RCA: 316] [Impact Index Per Article: 45.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 02/03/2017] [Accepted: 02/12/2017] [Indexed: 12/15/2022]
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Abstract
Critical care medicine is a young specialty that has experienced an expansion of research efforts in the last decade. Many physiologic and therapeutic principles or “dogmas” have been challenged, resulting in major “shifts” and minor “drifts” in thinking. This article reviews the available literature about some of these important and sometimes controversial changes, with emphasis on the practical implications of the concepts. Specific areas discussed include supply-dependent oxygen consumption in critical illness, manipulation of the cytokine cascade in sepsis, ventilation in the acute respiratory distress syndrome (ARDS), blood transfusion in the critically ill, the concept of the multiple organ dysfunction syndrome (MODS), the need for nutritional support in the critically ill, and others. Many of the changes discussed involve the recognition that the host response to a severe insult is exceedingly complex, and the understanding of this response and the effects of it at a tissue and cellular level are incomplete. As a result, the ability to impact the outcome of sepsis and MODS has thus far been disappointing, with the possible exception of “lung-protective” ventilation. The final challenge in critical care medicine is to gain information that will allow the practitioner to better understand, prevent, and treat the complex events that result in organ and cellular dysfunction. Future changes in dogma are welcome if they help achieve these goals.
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Affiliation(s)
- Ari Robin Joffe
- Department of Pediatrics, University of Alberta Hospital, University of Alberta, Edmonton, Alberta, Canada.
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Abstract
Useful resuscitation endpoints must serve both to diagnose the need for and to ensure the ongoing adequacy of resuscitation. To this end, traditional measures of organ perfusion are now widely appreciated to be grossly inadequate. Useful endpoints or milestones range from the global, to the regional, to the cellular specific. Understanding the basic principles of perfusion-related dysoxia in trauma and hemorrhage and its potential rapid transition to involve inflammatory and immune responses on cellular oxygen utilization will aid the clinician in choosing and appropriately interpreting endpoint monitoring data. There also appears to be an optimal window of opportunity for monitoring to help mitigate the development of more complicated inflammatory states. This article reviews the underlying need for endpoint selection (both global and regional, biochemical and functional) and monitoring during resuscitation of the polytrauma patient. At this juncture it appears that early use of a blend of global markers such as lactate and base deficit coupled with an available sensitive regional monitor such as gastric tonometry may offer the best combination of current technology to guard against early perfusion-related dysoxia. Future techniques involving optical spectroscopy offer the exciting potential to assess oxygenation at the cellular level. This may aid in ultra-early detection and resolution of perfusion-related dysoxia in addition to recognizing its transition to more complex inflammatory-mediated circulatory and metabolic failure.
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Affiliation(s)
- Kevin R. Ward
- Virginia Commonwealth University Reanimation Engineering and Shock Center (VCURES), Richmond, VA., Departments of Emergency Medicine and Physiology, Virginia Commonwealth University, Richmond, VA., Department of Surgery and Section of Trauma and Surgical Critical Care, Virginia Commonwealth University, Richmond, VA
| | - Rao R. Ivatury
- Virginia Commonwealth University Reanimation Engineering and Shock Center (VCURES), Richmond, VA., Departments of Emergency Medicine and Physiology, Virginia Commonwealth University, Richmond, VA., Department of Surgery and Section of Trauma and Surgical Critical Care, Virginia Commonwealth University, Richmond, VA
| | - R. Wayne Barbee
- Virginia Commonwealth University Reanimation Engineering and Shock Center (VCURES), Richmond, VA., Departments of Emergency Medicine and Physiology, Virginia Commonwealth University, Richmond, VA
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Intravenous thiamine is associated with increased oxygen consumption in critically ill patients with preserved cardiac index. Ann Am Thorac Soc 2015; 11:1597-601. [PMID: 25390455 DOI: 10.1513/annalsats.201406-259bc] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Oxygen consumption may be impaired in critically ill patients. OBJECTIVES To evaluate the effect of intravenous thiamine on oxygen consumption ([Formula: see text]o2) in critically ill patients. METHODS This was a small, exploratory open-label pilot study conducted in the intensive care units at a tertiary care medical center. Critically ill adults requiring mechanical ventilation were screened for enrollment. Oxygen consumption ([Formula: see text]o2) and cardiac index (CI) were recorded continuously for 9 hours. After 3 hours of baseline data collection, 200 mg of intravenous thiamine was administered. The outcome was change in [Formula: see text]o2 after thiamine administration. MEASUREMENTS AND MAIN RESULTS Twenty patients were enrolled and 3 were excluded because of incomplete [Formula: see text]o2 data, leaving 17 patients for analysis. There was a trend toward increase in [Formula: see text]o2 after thiamine administration (16.3 ml/min, SE 8.5; P = 0.052). After preplanned adjustment for changes in CI in case of a delivery-dependent state in some patients (with exclusion of one additional patient because of missing CI data), this became statistically significant (16.9 ml/min, SE 8.6; P = 0.047). In patients with average CI greater than our cohort's mean value of 3 L/min/m(2), [Formula: see text]o2 increased by 70.9 ml/min (±16; P < 0.0001) after thiamine. Thiamine had no effect in patients with reduced CI (< 2.4 L/min/m(2)). There was no association between initial thiamine level and change in [Formula: see text]o2 after thiamine administration. CONCLUSIONS The administration of a single dose of thiamine was associated with a trend toward increase in [Formula: see text]o2 in critically ill patients. There was a significant increase in [Formula: see text]o2 in those patients with preserved or elevated CI. Further study is needed to better characterize the role of thiamine in oxygen extraction. Clinical trial registered with www.clinicaltrials.gov (NCT01462279).
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Blood content analysis for evaluating cardiopulmonary function. Curr Opin Crit Care 2014; 19:258-64. [PMID: 23563924 DOI: 10.1097/mcc.0b013e328360aadd] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW To review the role of blood analysis in cardiac and pulmonary evaluation. RECENT FINDINGS A comprehensive understanding of arterial blood gas analysis - often aided by venous blood gas analysis, to help determine the ideal levels of blood oxygenation and hemoglobin (Hb), is reviewed in light of the recent findings. Serum lactate plays an important role in assessing cardiopulmonary function; yet, with the exception of prognosis, as to exactly what an elevated lactate implies remains unclear. Despite considerable research into the pulmonary-specific biomarkers, none are currently sufficiently robust to use in daily practice. Of the cardiac biomarkers, the natriuretic peptides are yet to be established in critical care practice apart from a role in assisting weaning from a ventilator, and cardiac troponin (cTn) continues to be an essential tool. SUMMARY The ongoing research on blood contents has not resulted in any new outstanding markers to the critical care physician to use in evaluating cardiopulmonary function, with the exception of high-sensitive cTn. Yet, many recent studies assist the clinician by providing a better understanding of how to use routine tools, like arterial and venous blood gas analysis, more effectively and offer guidance in optimizing Hb and lactate blood levels.
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Shere-Wolfe RF, Galvagno SM, Grissom TE. Critical care considerations in the management of the trauma patient following initial resuscitation. Scand J Trauma Resusc Emerg Med 2012; 20:68. [PMID: 22989116 PMCID: PMC3566961 DOI: 10.1186/1757-7241-20-68] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2012] [Accepted: 08/28/2012] [Indexed: 12/20/2022] Open
Abstract
Background Care of the polytrauma patient does not end in the operating room or resuscitation bay. The patient presenting to the intensive care unit following initial resuscitation and damage control surgery may be far from stable with ongoing hemorrhage, resuscitation needs, and injuries still requiring definitive repair. The intensive care physician must understand the respiratory, cardiovascular, metabolic, and immunologic consequences of trauma resuscitation and massive transfusion in order to evaluate and adjust the ongoing resuscitative needs of the patient and address potential complications. In this review, we address ongoing resuscitation in the intensive care unit along with potential complications in the trauma patient after initial resuscitation. Complications such as abdominal compartment syndrome, transfusion related patterns of acute lung injury and metabolic consequences subsequent to post-trauma resuscitation are presented. Methods A non-systematic literature search was conducted using PubMed and the Cochrane Database of Systematic Reviews up to May 2012. Results and conclusion Polytrauma patients with severe shock from hemorrhage and massive tissue injury present major challenges for management and resuscitation in the intensive care setting. Many of the current recommendations for “damage control resuscitation” including the use of fixed ratios in the treatment of trauma induced coagulopathy remain controversial. A lack of large, randomized, controlled trials leaves most recommendations at the level of consensus, expert opinion. Ongoing trials and improvements in monitoring and resuscitation technologies will further influence how we manage these complex and challenging patients.
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Affiliation(s)
- Roger F Shere-Wolfe
- University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, 22 S. Greene St, Ste. T1R77, Baltimore, MD 21201, USA.
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10
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Abstract
Patients with critical illness are heterogeneous, with differing physiologic requirements over time. Goal-directed therapy in the emergency room demonstrates that protocolized care could result in improved outcomes. Subsequent studies have confirmed benefit with such a "bundle-based approach" in the emergency room and in preoperative and postoperative scenarios. However, this cannot be necessarily extrapolated to the medium-term and long-term care pathway of the critically ill patient. It is likely that the development of mitochondrial dysfunction could result in goal-directed types of approaches being detrimental. Equally, arterial pressure aims are likely to be considerably different as the patient's physiology moves toward "hibernation." The agents we utilize as sedative and pressor agents have considerable effects on immune function and the inflammatory profile, and should be considered as part of the total clinical picture. The role of gut failure in driving inflammation is considerable, and the drive to feed enterally, regardless of aspirate volume, may be detrimental in those with degrees of ileus, which is often a difficult diagnosis in the critically ill. The pathogenesis of liver dysfunction may be, at least in part, related to venous engorgement that will contribute toward portal hypertension and gut edema. This, in association with loss of the hepatosplanchnic buffer response, it is likely to contribute to venous pooling in the abdominal cavity, impaired venous return, and decreased central blood volumes. Therapies such as those used in "small-for-size syndrome" may have a role in the chronic stages of septic vascular failure.
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Cavazzoni SLZ, Guglielmi M, Parrillo JE, Walker T, Dellinger RP, Hollenberg SM. Ventricular Dilation Is Associated With Improved Cardiovascular Performance and Survival in Sepsis. Chest 2010; 138:848-55. [DOI: 10.1378/chest.09-1086] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Nichols D. Septic shock. Crit Care Clin 2010; 26:xiii-xiv. [PMID: 20381717 DOI: 10.1016/j.ccc.2010.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Dane Nichols
- Division of Pulmonary-Critical Care Medicine, Oregon Health & Sciences University, Portland, OR, USA.
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Reinhart K, Brunkhorst FM, Bone HG, Bardutzky J, Dempfle CE, Forst H, Gastmeier P, Gerlach H, Gründling M, John S, Kern W, Kreymann G, Krüger W, Kujath P, Marggraf G, Martin J, Mayer K, Meier-Hellmann A, Oppert M, Putensen C, Quintel M, Ragaller M, Rossaint R, Seifert H, Spies C, Stüber F, Weiler N, Weimann A, Werdan K, Welte T. [Prevention, diagnosis, treatment, and follow-up care of sepsis. First revision of the S2k Guidelines of the German Sepsis Society (DSG) and the German Interdisciplinary Association for Intensive and Emergency Care Medicine (DIVI)]. Anaesthesist 2010; 59:347-70. [PMID: 20414762 DOI: 10.1007/s00101-010-1719-5] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- K Reinhart
- Klinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Jena der Friedrich-Schiller-Universität Jena, Erlanger Allee 101, 07747 Jena.
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Reinhart K, Brunkhorst FM, Bone HG, Bardutzky J, Dempfle CE, Forst H, Gastmeier P, Gerlach H, Gründling M, John S, Kern W, Kreymann G, Krüger W, Kujath P, Marggraf G, Martin J, Mayer K, Meier-Hellmann A, Oppert M, Putensen C, Quintel M, Ragaller M, Rossaint R, Seifert H, Spies C, Stüber F, Weiler N, Weimann A, Werdan K, Welte T. 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)). GERMAN MEDICAL SCIENCE : GMS E-JOURNAL 2010; 8:Doc14. [PMID: 20628653 PMCID: PMC2899863 DOI: 10.3205/000103] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/21/2010] [Indexed: 12/16/2022]
Abstract
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 1st 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.
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Affiliation(s)
- K Reinhart
- University Hospital Jena, Clinic for Anaesthesiology and Intensive Care Therapy, Jena, Germany
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Nichols D, Nielsen ND. Oxygen Delivery and Consumption: A Macrocirculatory Perspective. Crit Care Clin 2010; 26:239-53, table of contents. [DOI: 10.1016/j.ccc.2009.12.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Abstract
The measurement of cardiac output in critical care appears to be increasingly common. However, both the monitoring technologies and the therapeutic approaches they inform have often proved highly controversial. As the range of alternative technologies available continues to increase, it seems worthwhile to question whether this monitoring modality should be used at all. The aim of this pro-con debate is to review the key evidence and to explain the often quite widely differing interpretations placed upon it. The term cardiac output monitoring refers to technology, whose primary purpose is to monitor global blood flow. The principles of the various technologies have been reviewed elsewhere.1
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Exline MC, Crouser ED. Mitochondrial mechanisms of sepsis-induced organ failure. FRONTIERS IN BIOSCIENCE : A JOURNAL AND VIRTUAL LIBRARY 2008; 13:5030-41. [PMID: 18508567 DOI: 10.2741/3061] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Sepsis is the leading cause of death in medical intensive care units. Though progress has been made in the early treatment of sepsis associated with hemodynamic collapse (septic shock), little is known about the pathogenesis of delayed organ dysfunction during sepsis. A growing body of data indicates that sepsis is associated with acute changes in cell metabolism, and that mitochondria are particularly susceptible. The severity of mitochondrial pathology varies according to host and pathogen factors, and appears to correlate with loss of organ dysfunction. In this regard, low levels of cell apoptosis and mitochondrial turnover are normally observed in all metabolically active tissues; however, these homeostatic mechanisms are frequently overwhelmed during sepsis and contribute to cell and tissue pathology. Thus, a better understanding of the mechanisms regulating mitochondrial damage and repair during severe sepsis may provide new treatment options and better outcomes for this deadly disease (30-60% mortality). Herein, we present compelling evidence linking mitochondrial apoptosis pathways to sepsis-induced cell and organ failure and discuss the implications in terms of future sepsis research.
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Affiliation(s)
- Matthew C Exline
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, The Ohio State University Medical Center, Columbus, Ohio 43210-1252, USA.
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Abstract
Intensive care medicine was for many years practiced within the four walls of an intensive care unit (ICU). Evidence then emerged that many serious adverse events in hospitals were preceded by many hours of slow deterioration, resulting in multi-organ failure and potentially preventable admissions to the ICU. Ironically, these admissions may have been prevented if the skills within the ICU had been available to the patient on the general ward at an earlier stage. The concept of a Medical Emergency Team (MET) was developed to enable staff from the ICU to rapidly identify and respond to serious illness at an earlier stage and, hopefully, prevent serious complications. Since then, other forms of rapid response and outreach systems have been developed. Increasingly, physicians working in ICUs can see the benefit of the early management of serious illness in order to improve patient outcome.
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Affiliation(s)
- Ken Hillman
- University of New South Wales; Critical Care Services, Sydney South West Area Health Service, Sydney, Australia.
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Grocott M, Richardson A, Montgomery H, Mythen M. Caudwell Xtreme Everest: a field study of human adaptation to hypoxia. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2008; 11:151. [PMID: 17672886 PMCID: PMC2206524 DOI: 10.1186/cc5921] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Caudwell Xtreme Everest (CXE) is a large healthy volunteer field study investigating human adaptation to environmental hypoxia. More than 200 individuals were studied at sea-level and in four laboratories on the trek to Everest Base Camp (5,300 m). Fifteen physicians climbed high on Everest and continued the studies as they ascended; eight of these individuals reached the summit of Everest and succeeded in sampling arterial blood at 8,400 m on their descent. Core measurements included cardiopulmonary exercise testing, neuropsychological assessment, near infra-red spectroscopy of brain and exercising muscle, blood markers and daily recording of simple physiological variables. The goal of CXE is to further our understanding of human adaptation to cellular hypoxia, a fundamental mechanism of injury in critical illness, with the aim of improving the care of critically ill patients.
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Affiliation(s)
- Mike Grocott
- Centre for Altitude, Space and Extreme Environment Medicine (CASE Medicine), UCL Institute of Human Health and Performance, Ground Floor, Charterhouse Building, UCL Archway Campus, Highgate Hill, London, N19 5LW, UK
| | - Alan Richardson
- Chelsea School, University of Brighton, Hillbrow, Denton Road, Eastbourne BN20 7SR, UK
| | - Hugh Montgomery
- Centre for Altitude, Space and Extreme Environment Medicine (CASE Medicine), UCL Institute of Human Health and Performance, Ground Floor, Charterhouse Building, UCL Archway Campus, Highgate Hill, London, N19 5LW, UK
| | - Monty Mythen
- Centre for Altitude, Space and Extreme Environment Medicine (CASE Medicine), UCL Institute of Human Health and Performance, Ground Floor, Charterhouse Building, UCL Archway Campus, Highgate Hill, London, N19 5LW, UK
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Evolving paradigms in acute kidney injury. Crit Care Med 2007; 35:2866-7. [PMID: 18043210 DOI: 10.1097/01.ccm.0000295269.18286.7b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Evolving paradigms in acute kidney injury *. Crit Care Med 2007. [DOI: 10.1097/00003246-200712000-00034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Reinhart K, Brunkhorst FM, Bone HG, Gerlach H, Gründling M, Kreymann G, Kujath P, Marggraf G, Mayer K, Meier-Hellmann A, Peckelsen C, Putensen C, Stüber F, Quintel M, Ragaller M, Rossaint R, Weiler N, Welte T, Werdan K. [Diagnosis and therapy of sepsis]. Clin Res Cardiol 2007; 95:429-54. [PMID: 16868790 DOI: 10.1007/s00392-006-0414-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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).
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Affiliation(s)
- K Reinhart
- Universitätsklinikum Jena der Friedrich-Schiller-Universität Jena, Klinik für Anästhesiologie und Intensivtherapie, Jena
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Abstract
PURPOSE OF REVIEW The inflammatory or stress response to injury has evolved to ensure survival. This review will examine this response in otherwise healthy patients. Additionally, the impact of several common comorbid conditions on the inflammatory response will be considered. What will become evident is that the stress response may be exaggerated in some conditions and suppressed in others. Rapid identification of both an abnormal response and its cause will allow clinicians to maximize a patient's healing potential. RECENT FINDINGS Recent work has shown that an altered inflammatory response has marked effects on both immune competence and the endocrine system. Investigations are ongoing to delineate the mechanism of lymphocyte dysfunction. With regard to critical care endocrinopathies, the effects of insulin and hyperglycemia on inflammation and wound healing are being investigated. SUMMARY An understanding of the stress response will aid the clinician in preparing for expected responses, recognizing and perhaps correcting deviations from the norm and accounting for potential complications that arise in the face of preexisting disease. Deviations from the normal time course may represent the effects of preexisting medical illness, treatment or postoperative/injury complications.
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Affiliation(s)
- Benjamin A Kohl
- University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
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Reinhart K, Brunkhorst F, Bone H, Gerlach H, Gründling M, Kreymann G, Kujath P, Marggraf G, Mayer K, Meier-Hellmann A, Peckelsen C, Putensen C, Quintel M, Ragaller M, Rossaint R, Stüber F, Weiler N, Welte T, Werdan K. [Diagnosis and therapy of sepsis. Guidelines of the German Sepsis Society Inc. and the German Interdisciplinary Society for Intensive and Emergency Medicine]. Internist (Berl) 2006; 47:356, 358-60, 362-8, passim. [PMID: 16532281 DOI: 10.1007/s00108-006-1595-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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).
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Affiliation(s)
- K Reinhart
- Klinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum der Friedrich-Schiller-Universität Jena
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Asensio JA, Petrone P, Wo CJ, Li-Chien C, Lu K, Fathizadeh P, Kimbrell BJ, García-Núñez LM, Shoemaker WC. Noninvasive hemodynamic monitoring of patients sustaining severe penetrating thoracic, abdominal and thoracoabdominal injuries for early recognition and therapy of shock. Scand J Surg 2006; 95:152-7. [PMID: 17066608 DOI: 10.1177/145749690609500304] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- J A Asensio
- Division of Trauma Surgery and Surgical Critical Care, Department of Surgery, University of Southern California Keck School of Medicine, Los Angeles, California, USA.
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Shoemaker WC, Wo CCJ, Chien LC, Lu K, Ahmadpour N, Belzberg H, Demetriades D. Evaluation of invasive and noninvasive hemodynamic monitoring in trauma patients. ACTA ACUST UNITED AC 2006; 61:844-53; discussion 853-4. [PMID: 17033550 DOI: 10.1097/01.ta.0000197925.92635.56] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The aim of this study was to compare a recently developed and improved noninvasive hemodynamic monitoring system with the conventional invasive monitoring by pulmonary artery catheterization (PAC) in acute emergency trauma patients. METHODS In a large, university-run, inner city public hospital, we monitored 993 trauma patients noninvasively; 262 of these were simultaneously monitored with both noninvasive hemodynamic and invasive PAC monitoring. The noninvasive monitoring was begun shortly after admission to the emergency department and the invasive PAC monitoring was started in the operating room, or as soon as the patient arrived in the intensive care unit. Noninvasive monitoring included cardiac index (CI) by the IQ or Physio Flow bioimpedance device, together with mean arterial blood pressure, heart rate, pulse oximetry (SapO2), transcutaneous oxygen (PtcO2), and carbon dioxide (PtcCO2) tensions. We compared CI by simultaneous measurements with both invasive and noninvasive methods 907 times in 262 patients. RESULTS The CI by thermodilution (CItd) correlated well with simultaneous measurements with the bioimpedance (CIbi), r2 = 0.915, r2 = 0.84, p < 0.001. The bias and precision of simultaneous measurements was -0.070 +/- 0.47 L/min/m2; agreement was considered satisfactory. In the initial resuscitation period of both monitoring systems, the CI, mean arterial blood pressure, SapO2, and tissue perfusion (reflected by invasive DO2 and VO2, and by noninvasive PtcO2/FiO2 ratio) were higher in survivors than in nonsurvivors, whereas heart rate values were higher in the nonsurvivors. We concluded that noninvasive hemodynamic monitoring provided a feasible, safe, inexpensive, accurate, continuous, on-line real-time graphic displays that are equivalent to the essential features of invasive pulmonary artery catheter monitoring.
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Affiliation(s)
- William C Shoemaker
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California 90033, USA.
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Reinhart K, Brunkhorst FM, Bone HG, Gerlach H, Gründling M, Kreymann G, Kujath P, Marggraf G, Mayer K, Meier-Hellmann A, Peckelsen C, Putensen C, Stüber F, Quintel M, Ragaller M, Rossaint R, Weiler N, Welte T, Werdan K. Diagnose und Therapie der Sepsis. ACTA ACUST UNITED AC 2006. [DOI: 10.1007/s00390-006-0700-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Shoemaker WC, Wo CCJ, Lu K, Chien LC, Bayard DS, Belzberg H, Demetriades D, Jelliffe RW. Outcome Prediction by a Mathematical Model Based on Noninvasive Hemodynamic Monitoring. ACTA ACUST UNITED AC 2006; 60:82-90. [PMID: 16456440 DOI: 10.1097/01.ta.0000203109.71608.64] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The aims are to apply a mathematical search and display model based on noninvasive hemodynamic monitoring, to predict outcome early in a consecutively monitored series of 661 severely injured patients. METHODS A prospective observational study by a previously designed protocol in a Level I trauma service in a university-run inner city public hospital was conducted. The survival probabilities were calculated at the initial resuscitation on admission and at subsequent intervals during their hospitalization beginning shortly after admission to the emergency department. Cardiac function was evaluated by cardiac output (CI), heart rate (HR), and mean arterial blood pressure (MAP), pulmonary function by pulse oximetry (SapO2), and tissue perfusion function by transcutaneous oxygen indexed to FiO2, (PtcO2/FiO2), and carbon dioxide (PtcCO2) tension. RESULTS The survival probability (SP) averaged 89 +/- 0.4% for survivors and 75.7 +/- 1.6% (p < 0.001) for nonsurvivors in the first 24-hour period of resuscitation. The CI, MAP, SapO2, PtcO2, and PtcO2/FiO2 were significantly higher in survivors than in nonsurvivors in initial resuscitation, whereas HR and PtcCO2 were higher in nonsurvivors. CONCLUSIONS During the initial resuscitation period, misclassifications were 102 of 661 or 15%. The SP provided early objective criteria to evaluate hospital outcome and to track changes throughout the hospital course based on a large database of patients with similar clinical-hemodynamic states.
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Affiliation(s)
- William C Shoemaker
- Laboratory of Applied Pharmcokinetics, Department of Surgery, LAC+USC Medical Center, Keck School of Medicine, University of Southern California, 1200 N. State Street, Los Angeles, CA 90033, USA.
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Kusano C, Baba M, Takao S, Sane S, Shimada M, Shirao K, Natsugoe S, Fukumoto T, Aikou T. Oxygen delivery as a factor in the development of fatal postoperative complications after oesophagectomy. Br J Surg 2005. [DOI: 10.1046/j.1365-2168.1997.02542.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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32
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Suzuki T, Morisaki H, Serita R, Yamamoto M, Kotake Y, Ishizaka A, Takeda J. Infusion of the β-adrenergic blocker esmolol attenuates myocardial dysfunction in septic rats*. Crit Care Med 2005; 33:2294-301. [PMID: 16215384 DOI: 10.1097/01.ccm.0000182796.11329.3b] [Citation(s) in RCA: 122] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Since beta-blocker therapy is known to be effective in patients with an injured heart, such as infarction, we designed the present study to examine the protective effects of infusion of the beta1-selective blocker esmolol on myocardial function in peritonitis-induced septic rats using an isolated working heart preparation. DESIGN Randomized animal study. SETTING University research laboratory. SUBJECTS Thirty-one rats treated with cecal ligation and perforation to evoke peritonitis. INTERVENTIONS After cecal ligation and perforation, rats were randomly allocated to the control group (normal saline 2 mL/hr, n = 11), low-dose esmolol group (10 mg/kg/hr, n = 10), or high-dose esmolol group (20 mg/kg/hr, n = 10). After obtaining blood samples for measurement of arterial lactate and tumor necrosis factor-alpha at 24 hrs, we assessed cardiac output, myocardial oxygen consumption, and cardiac efficiency (cardiac output x peak systolic pressure/myocardial oxygen consumption) at various preloads in an isolated perfused heart preparation. MEASUREMENTS AND MAIN RESULTS Esmolol infusion did not cause an elevation of arterial lactate levels but reduced tumor necrosis factor-alpha concentrations vs. the control group (p < .05). Both cardiac output and cardiac efficiency in the esmolol-treated rats were significantly higher throughout the study periods vs. the control group (p < .05). CONCLUSIONS Esmolol infusion in sepsis improved oxygen utilization of myocardium and preserved myocardial function.
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Affiliation(s)
- Takeshi Suzuki
- Department of Anesthesiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
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Shoemaker WC, Bayard DS, Botnen A, Wo CCJ, Gandhi A, Chien LC, Lu K, Martin MJ, Chan LS, Demetriades D, Ahmadpour N, Jelliffe RW. Mathematical program for outcome prediction and therapeutic support for trauma beginning within 1 hr of admission: a preliminary report. Crit Care Med 2005; 33:1499-506. [PMID: 16003054 DOI: 10.1097/01.ccm.0000162641.92400.aa] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The aims were a) to noninvasively monitor acute emergency trauma patients beginning within 1 hr after admission to the emergency department; b) to prospectively predict outcome; and c) to evaluate the relative effectiveness of various modes of therapy. DESIGN Prospective outcome prediction study using a mathematical search and display model based on noninvasive hemodynamic monitoring. SETTING A level I trauma service in a large university-run inner-city public hospital. PATIENTS We studied 185 consecutively noninvasively monitored emergency patients. INTERVENTIONS We noninvasively monitored cardiac index, mean arterial blood pressure, heart rate, pulse oximetry, and transcutaneous oxygen and carbon dioxide tensions beginning within 1-hr after emergency admission. MEASUREMENTS AND MAIN RESULTS The cardiac index, pulse oximetry, transcutaneous oxygen tension, transcutaneous carbon dioxide tension, and mean arterial blood pressure were higher in survivors than in nonsurvivors in the initial resuscitation period and at the hemodynamic nadir. Heart rate and transcutaneous carbon dioxide tension were higher in the nonsurvivors. The calculated survival probability in the first hour observation period of survivors averaged 85 +/- 14% vs. 69 +/- 16% for nonsurvivors (p = .0001). Misclassifications of the series as a whole were 11.3%; after excluding brain death from severe head injury, there were 6.4% misclassifications. A decision support system evaluated the effects of various therapies based on responses of patients with similar clinical-hemodynamic states. CONCLUSION Noninvasive hemodynamic monitoring and an information system provided a feasible approach to predict outcome early and to evaluate prospectively the efficacy of various therapies.
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Affiliation(s)
- William C Shoemaker
- Laboratory of Applied Pharmacokinetics, LAC+USC Medical Center, Keck School of Medicine, University of Southern California, Los Angeles CA, USA
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Haskins SC, Pascoe PJ, Ilkiw JE, Fudge M, Hopper K, Aldrich J. The effect of moderate hypovolemia on cardiopulmonary function in dogs. J Vet Emerg Crit Care (San Antonio) 2005. [DOI: 10.1111/j.1476-4431.2005.00129.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Davies SJ, Wilson RJT. Preoperative optimization of the high-risk surgical patient. Br J Anaesth 2004; 93:121-8. [PMID: 15121729 DOI: 10.1093/bja/aeh164] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- S J Davies
- Department of Anaesthetics, York Hospital, Wigginton Road, York YO31 8HE, UK
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Spronk PE, Zandstra DF, Ince C. Bench-to-bedside review: sepsis is a disease of the microcirculation. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2004; 8:462-8. [PMID: 15566617 PMCID: PMC1065042 DOI: 10.1186/cc2894] [Citation(s) in RCA: 176] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Microcirculatory perfusion is disturbed in sepsis. Recent research has shown that maintaining systemic blood pressure is associated with inadequate perfusion of the microcirculation in sepsis. Microcirculatory perfusion is regulated by an intricate interplay of many neuroendocrine and paracrine pathways, which makes blood flow though this microvascular network a heterogeneous process. Owing to an increased microcirculatory resistance, a maldistribution of blood flow occurs with a decreased systemic vascular resistance due to shunting phenomena. Therapy in shock is aimed at the optimization of cardiac function, arterial hemoglobin saturation and tissue perfusion. This will mean the correction of hypovolemia and the restoration of an evenly distributed microcirculatory flow and adequate oxygen transport. A practical clinical score for the definition of shock is proposed and a novel technique for bedside visualization of the capillary network is discussed, including its possible implications for the treatment of septic shock patients with vasodilators to open the microcirculation.
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Affiliation(s)
- Peter E Spronk
- Department of Intensive Care Medicine, Gelre ziekenhuizen, Apeldoorn, The Netherlands.
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Shah A, Connolly CM, Kirschner RA, Herndon DN, Kramer GC. Evaluation of Hyperdynamic Resuscitation in 60% TBSA Burn-Injured Sheep. Shock 2004; 21:86-92. [PMID: 14676689 DOI: 10.1097/01.shk.0000101666.49265.b4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
It has been suggested that hyperdynamic (HD) resuscitation improves outcomes. We hypothesized that initial HD resuscitation of burn injury using fluid and inotropes would improve metabolic function as indicated by base excess. We used an anesthetized ovine model of 60% TBSA full-thickness flame burn with delayed resuscitation started at 90 min after burn and continued for 8 h. Three groups (n = 6 each) were included: 1) HD defined as cardiac index (CI) of 1.5x baseline achieved by using Ringer's lactate alone (HD-Fluid); 2) Ringer's lactate and dobutamine (HD-Drug); and 3) Parkland Formula (Parkland) as a control group. Statistical analysis performed using analysis of variance and Tukey's HSD test. Significance accepted at P < 0.05. Higher CI was achieved in both HD-Fluid and HD-Drug groups, e.g., at 8 h the CI was 4.6 +/- 0.4 and 4.7 +/- 0.6 L/min/m respectively, as compared with Parkland 3.6 +/- 0.5 L/min/m. The net fluid balance (fluid infused - urine output) was similar in both Parkland and HD-Drug groups, which were 2.5x more in HD-Fluid (P = 0.001). The mean postburn urinary outputs were similar in both Parkland and HD-Drug groups, e.g., Parkland (0.9 +/- 0.08 mL/kg/h), HD-Drug (1.0 +/- 0.2 mL/kg/h) and increased in HD-Fluid (3.7 +/- 1.0 mL/kg/h; P = 0.0005). Base excess remained positive in both HD-Drug (+2.5 +/- 1 mmol/L) and Parkland (+1.5 +/- 1.7 mmol/L), and declined to -4.0 +/- 3.6 mmol/L in HD-Fluid group (P = 0.036). We conclude that there may be no benefit to using hyperdynamic regimens for the initial resuscitation of burn injury.
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Affiliation(s)
- Alia Shah
- Resuscitation Research Laboratory, Department of Anesthesiology, University of Texas Medical Branch, Galveston, Texas 77555, USA
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McKinley BA, Valdivia A, Moore FA. Goal-oriented shock resuscitation for major torso trauma: what are we learning? Curr Opin Crit Care 2003; 9:292-9. [PMID: 12883284 DOI: 10.1097/00075198-200308000-00007] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Shock resuscitation is an obligatory intervention for severely injured patients who present in shock. During the past 15 years, with widespread acceptance of "damage control" surgery and early triage to the intensive care unit (ICU) to optimize resuscitation, the lives of many major trauma victims have been saved, and much has been learned about shock resuscitation. Due largely to the work of Shoemaker et al., a resuscitation strategy based on a standardized process using O(2) delivery index (DO(2)I) as an endpoint and physiologic performance goal for interventions has been developed, studied, and refined for resuscitation of shock caused by major trauma. DO(2)I >or=600 mL O(2)/min-m2 is the only resuscitation endpoint variable that has been tested in prospective randomized trials (PRTs) of trauma patient outcome. These PRTs are limited, and their results are not conclusive. Results from other investigators, including our group, using similar process and endpoints, are indicating similar performance and outcomes. We believe that DO(2)I is a useful endpoint because it integrates three important variables, ie, hemoglobin concentration [Hb], arterial hemoglobin O(2) saturation, and cardiac output. We have found DO(2)I >or=500 mL O(2)/min-m2 to be an endpoint with more general applicability, but we believe that the standardized process is more important than the specific endpoint. To standardize our process, we have developed a computerized decision support tool for shock resuscitation. This technology has provided novel data collection and has permitted refinement of the bedside process. Our data analysis indicates that the next challenge will be to develop a similar pre ICU resuscitation process that will use less invasive monitors and different endpoints. Identification of the high-risk resuscitation nonresponders early in the resuscitation process will be needed to redirect their clinical trajectories. As an endpoint for interventions for goal-directed resuscitation in the critically injured trauma patient, systemic O(2) delivery is the current state of the art and the basis for near future development of clinical processes for resuscitation of shock due to major trauma.
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Affiliation(s)
- Bruce A McKinley
- Department of Surgery, University of Texas-Health Science Center at Houston, Medical School, Houston, Texas 77030, USA.
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Vincent JL. The International Sepsis Forum's frontiers in sepsis: High cardiac output should be maintained in severe sepsis. Crit Care 2003; 7:276-8. [PMID: 12930548 PMCID: PMC270704 DOI: 10.1186/cc2349] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Despite a usually normal or high cardiac output, severe sepsis is associated with inadequate tissue oxygenation, leading to organ failure and death. Some authors have suggested that raising cardiac output and oxygen delivery to predetermined supranormal values may be associated with improved survival. While this may be of benefit in certain patients, bringing all patients to similar, supranormal values, is simplistic. It is much preferable to titrate therapy according to the needs of each individual patient. A combination of variables should be used for this purpose, in addition to a careful clinical evaluation, including not only cardiac output but also the mixed venous oxygen saturation and the blood lactate concentrations. The concept is to assess the adequacy of the cardiac output in patients with severe sepsis, enabling management strategies aimed at optimizing cardiac output to be tailored to the individual patient.
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Affiliation(s)
- Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, University of Brussels, Brussels, Belgium.
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40
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Abstract
Critical care medicine is a relatively young specialty that was developed in response to potentially reversible life-threatening illness and was facilitated by developments such as new drugs, support equipment, and monitoring technology. It has been largely practiced within the four walls of an intensive care unit (ICU). However, now there are increasing numbers of critically ill and at-risk patients in acute hospitals who are suffering potentially preventable, serious complications that may result in death because of a lack of appropriate systems, skills, and expertise outside of the ICU. Critical care specialists are expanding their roles beyond the four walls of their ICUs and becoming involved with strategies such as the medical emergency team, a concept designed to recognize critical illness early and to respond rapidly to resuscitate patients wherever they are in the hospital.
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Affiliation(s)
- Ken Hillman
- Department of Intensive Care, University of New South Wales, Sydney, Australia.
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41
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McKinley BA, Kozar RA, Cocanour CS, Valdivia A, Sailors RM, Ware DN, Moore FA. Normal versus supranormal oxygen delivery goals in shock resuscitation: the response is the same. THE JOURNAL OF TRAUMA 2002; 53:825-32. [PMID: 12435930 DOI: 10.1097/00005373-200211000-00004] [Citation(s) in RCA: 79] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Shock resuscitation is integral to early management of severely injured patients. Our standardized shock resuscitation protocol, developed in 1997 and implemented as a computerized intensive care unit (ICU) bedside decision support tool in 2000, used oxygen delivery index (Do I) > or = 600 mL/min/m as the intervention endpoint. In a recent publication, Shoemaker et al. refuted positive outcome effect of early supranormal Do (i.e., Do I > or = 600) resuscitation. In response to and because of ongoing concern for excessive volume loading, we decreased our Do I endpoint from 600 to 500. Our hypothesis was that by decreasing the Do I endpoint, less crystalloid would be administered. We compare resuscitation responses to the protocol with goals of Do I > or = 600 versus 500 in two patient cohorts. METHODS A standardized protocol was used to direct bedside decisions for resuscitation of patients with major injury (Injury Severity Score > 15), blood loss (> or = 6 units of packed red blood cells), metabolic stress (base deficit > or = 6 mEq/L), and no severe brain injury. The protocol logic is to attain and maintain Do I > or = a specified goal for the first 24 ICU hours using primarily blood and volume loading. Two cohorts were compared: Do I > or = 500 (18 patients admitted February-August 2001) versus Do I > or = 600 (18 patients admitted during 2000 age and gender matched with the Do I > or = 500 group). Data were analyzed using analysis of variance, chi, and t tests (p < 0.05). RESULTS Both groups had similar demographics (age 30 +/- 3 years; 78% men; Injury Severity Score 27 +/- 3), hemodynamics, and severity of shock at start of resuscitation in the ICU. Resuscitation response was Do I increase to > or = 600 for both cohorts within approximately 12 hours. Throughout the 24-hour ICU process, the Do I > or = 500 cohort received less lactated Ringer's volume than the Do I > or = 600 cohort (total of 8 +/- 1 vs. 12 +/- 2 L; p < 0.05) and tended to receive less blood transfusion (total of 3 +/- 1 vs. 5 +/- 1 units of packed red blood cells). CONCLUSION Shock resuscitation using Do I > or = 500 was indistinguishable from Do I > or = 600 mL/min/m. Less volume loading was required to attain and maintain Do I > or = 500 than 600 using computerized protocol technology to standardize resuscitation during the first 24 ICU hours.
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Affiliation(s)
- Bruce A McKinley
- Department of Surgery, University of Texas-Houston Medical School, 77030, USA.
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Yang S, Lim YP, Zhou M, Salvemini P, Schwinn H, Josic D, Koo DJ, Chaudry IH, Wang P. Administration of human inter-alpha-inhibitors maintains hemodynamic stability and improves survival during sepsis. Crit Care Med 2002; 30:617-22. [PMID: 11990925 DOI: 10.1097/00003246-200203000-00021] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The major forms of human inter-alpha-inhibitor proteins circulating in the plasma are inter-alpha-inhibitor (IalphaI, containing one light peptide chain called bikunin and two heavy chains) and pre-alpha-inhibitor (PalphaI, containing one light and one heavy chain). Although it has been reported that a decrease in IalphaI/PalphaI is correlated with an increased mortality rate in septic patients, it remains unknown whether administration of IalphaI/PalphaI early after the onset of sepsis has any beneficial effects on the cardiovascular response and outcome of the septic animal. The aim of this study, therefore, was to determine whether IalphaI and PalphaI have any salutary effects on the depressed cardiovascular function, liver damage, and mortality rate after polymicrobial sepsis. DESIGN Prospective, controlled, randomized animal study. SETTING A university research laboratory. SUBJECTS Male adult rats were subjected to polymicrobial sepsis by cecal ligation and puncture or sham operation followed by the administration of normal saline (i.e., resuscitation). MEASUREMENTS AND MAIN RESULTS At 1 hr after cecal ligation and puncture, human IalphaI/PalphaI at a dose of 30 mg/kg body weight or vehicle (normal saline, 1 mL/rat) were infused intravenously over a period of 30 mins. At 20 hrs after cecal ligation and puncture (i.e., the late, hypodynamic stage of sepsis), cardiac output was measured by using a dye dilution technique, and blood samples were collected for assessing oxygen content. Oxygen delivery, consumption, and extraction ratio were determined. Plasma concentrations of liver enzymes alanine aminotransferase and aspartate aminotransferase as well as lactate and tumor necrosis factor-alpha also were measured. In additional animals, the necrotic cecum was excised at 20 hrs after cecal ligation and puncture with or without IalphaI/PalphaI treatment, and survival was monitored for 10 days thereafter. The results indicate that administration of human IalphaI/PalphaI early after the onset of sepsis maintained cardiac output and systemic oxygen delivery, whereas it increased oxygen consumption and extraction at 20 hrs after cecal ligation and puncture. The elevated concentrations of alanine aminotransferase, aspartate aminotransferase, tumor necrosis factor-alpha, and lactate were attenuated by IalphaI/PalphaI treatment. In addition, administration of human IalphaI/PalphaI improved the survival rate from 30% to 89% in septic animals at day 10 after cecal ligation and puncture and cecal excision. CONCLUSION Human IalphaI/PalphaI appears to be a useful agent for maintaining hemodynamic stability and improving survival during the progression of polymicrobial sepsis.
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Affiliation(s)
- Shaolong Yang
- Center for Surgical Research and Department of Surgery, University of Alabama at Birmingham, USA
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43
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45
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Honore PM, Jamez J, Wauthier M, Lee PA, Dugernier T, Pirenne B, Hanique G, Matson JR. Prospective evaluation of short-term, high-volume isovolemic hemofiltration on the hemodynamic course and outcome in patients with intractable circulatory failure resulting from septic shock. Crit Care Med 2000; 28:3581-7. [PMID: 11098957 DOI: 10.1097/00003246-200011000-00001] [Citation(s) in RCA: 320] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the effects of short-term, high-volume hemofiltration (STHVH) on hemodynamic and metabolic status and 28-day survival in patients with refractory septic shock. DESIGN Prospective, interventional. SETTING Intensive care unit (ICU), tertiary institution. PATIENTS Twenty patients with intractable cardiocirculatory failure complicating septic shock, who had failed to respond to conventional therapy. INTERVENTIONS STHVH, followed by conventional continuous venovenous hemofiltration. STHVH consisted of a 4-hr period during which 35 L of ultrafiltrate is removed and neutral fluid balance is maintained. Subsequent conventional continuous venovenous hemofiltration continued for at least 4 days. MEASUREMENTS AND MAIN RESULTS Cardiac index, systemic vascular resistance, pulmonary vascular resistance, oxygen delivery, mixed venous oxygen saturation, arterial pH, and lactate were measured serially. Fluid and inotropic support were managed by protocol. Therapeutic endpoints were as follows during STHVH: a) by 2 hrs, a > or =50% increase in cardiac index; b) by 2 hrs, a > or =25% increase in mixed venous saturation; c) by 4 hrs, an increase in arterial pH to >7.3; d) by 4 hrs, a > or =50% reduction in epinephrine dose. Patients who attained all four goals (11 of 20) were considered hemodynamic "responders"; patients who did not (9 of 20) were considered hemodynamic "nonresponders." There were no differences in baseline hemodynamic, metabolic, and Acute Physiology and Chronic Health Evaluation and Simplified Acute Physiology Scores between responders and nonresponders. Survival to 28 days was better among responders (9 of 11 patients) than among nonresponders (0 of 9). Factors associated with survival were hemodynamic-metabolic response status, time interval from ICU admission to initiation of STHVH, and body weight. CONCLUSIONS These data suggest that STHVH may be of major therapeutic value in the treatment of intractable cardiocirculatory failure complicating septic shock. Early initiation of therapy and adequate dose may improve hemodynamic and metabolic responses and 28-day survival.
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Affiliation(s)
- P M Honore
- Department of Intensive Care Medicine, St-Pierre Hospital, Ottignies, Belgium.
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Lobo SM, Salgado PF, Castillo VG, Borim AA, Polachini CA, Palchetti JC, Brienzi SL, de Oliveira GG. Effects of maximizing oxygen delivery on morbidity and mortality in high-risk surgical patients. Crit Care Med 2000; 28:3396-404. [PMID: 11057792 DOI: 10.1097/00003246-200010000-00003] [Citation(s) in RCA: 197] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE To evaluate the effects of maximizing the oxygen delivery on morbidity and mortality in patients >60 yrs of age and/or with chronic diseases of vital organs who underwent major elective surgery. DESIGN Prospective, randomized, controlled trial. SETTING A 24-bed general intensive care unit of a teaching hospital. PATIENTS Thirty-seven high-risk patients who underwent major surgery. INTERVENTIONS The hemodynamic and oxygen transport variables and outcomes in 18 patients (control group) treated to maintain normal values of oxygen delivery were compared with 19 patients (protocol group) treated to maintain "supranormal" values. Therapy in both groups consisted of volume expansion and, when necessary, dobutamine to reach target values, during the surgery and 24 hrs postoperatively. MEASUREMENTS AND MAIN RESULTS We interrupted the study because of a significant difference in the 60-day mortality rate. The mortality rate in the control group was significantly higher when compared with the protocol group (9/18 [50%] vs. 3/19 [15.7%], p < .05). The prevalence of clinical and infectious complications was higher in the control group than in the protocol group (67% and 31% respectively; relative risk, 0.47; 95% confidence interval, 0.226-0.991; p < .05) and there was a trend toward more severe organ dysfunction in nonachievers patients (17/24 [71%] vs. 6/13 [46%], relative risk, 0.65; 95% confidence interval, 0.343-1.237; NS). CONCLUSION Older patients with existing cardiorespiratory illness undergoing major surgery have a reduced morbidity and mortality when dobutamine is used to maximize oxygen transport.
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Affiliation(s)
- S M Lobo
- Department of Internal Medicine, Medical School FUNFARME, São José do Rio Preto, São Paulo, Brazil
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Poortmans G, Schüpfer G, Roosens C, Poelaert J. Transesophageal echocardiographic evaluation of left ventricular function. J Cardiothorac Vasc Anesth 2000; 14:588-98. [PMID: 11052447 DOI: 10.1053/jcan.2000.9439] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- G Poortmans
- Postoperative Cardiac Surgical ICU and Department of Cardiac Anesthesia, Ghent University Hospital, Belgium
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Balk RA. Pathogenesis and management of multiple organ dysfunction or failure in severe sepsis and septic shock. Crit Care Clin 2000; 16:337-52, vii. [PMID: 10768085 DOI: 10.1016/s0749-0704(05)70113-5] [Citation(s) in RCA: 111] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Organ system dysfunction is a common adverse sequelae of severe sepsis and septic shock and has been reported to be the most common cause of death in the noncoronary intensive care unit. The pathophysiology of the development of multiple organ system dysfunction is likely multifactoral and may take several different pathways. The frequency of specific organ system involvement is dependent on the definition used to describe the organ dysfunction. The presence of organ dysfunction has great clinical impact on the underlying disease process, can prolong the hospital stay, increase the cost of care, and has been associated with an increase in mortality rate. At present, there is no recognized specific treatment for established organ failure, this primary attention has been directed toward prevention.
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Affiliation(s)
- R A Balk
- Department of Internal Medicine, Rush Medical College, Chicago, Illinois, USA.
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Tuchschmidt J. Increasing splanchnic perfusion. Crit Care Med 1999; 27:2576-7. [PMID: 10579287 DOI: 10.1097/00003246-199911000-00045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Yang S, Cioffi WG, Bland KI, Chaudry IH, Wang P. Differential alterations in systemic and regional oxygen delivery and consumption during the early and late stages of sepsis. THE JOURNAL OF TRAUMA 1999; 47:706-12. [PMID: 10528605 DOI: 10.1097/00005373-199910000-00015] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Studies have indicated that regional changes in oxygen utilization during sepsis cannot be predicted from the changes in the whole body oxygen delivery (DO2) and consumption (VO2). The aim of this study, therefore, was to determine whether differential alterations in systemic and regional DO2 and VO2 occur during the early and late stages of sepsis. METHODS Adult male Sprague-Dawley rats were subjected to sepsis by cecal ligation and puncture (CLP). At 5 hours (i.e., the early, hyperdynamic phase of sepsis) or 20 hours (i.e., the late, hypodynamic phase) after CLP, cardiac output, and organ blood flow were measured by radioactive microspheres. Systemic and regional DO2 and VO2 were determined and plasma levels of lactate were measured. RESULTS Cardiac output and blood flow to the liver, small intestine, and kidneys increased at 5 hours and decreased at 20 hours after CLP. Although both systemic DO2 and VO2 increased at 5 hours after CLP, systemic DO2 but not VO2 decreased at 20 hours. At 5 hours after CLP, intestinal and renal DO2 increased. However, DO2 in all the tested organs decreased at 20 hours after CLP. VO2 increased in the liver, small intestine, and kidneys at 5 hours after CLP but decreased only in the liver and small intestine at 20 hours after the onset of sepsis. Moreover, plasma lactate levels increased at the late stage of sepsis. CONCLUSION Because hepatic and intestinal VO2 but not systemic and renal VO2 decreased at 20 hours after CLP, the liver and small intestine seem to be more vulnerable to the hypoxic insult during the hypodynamic stage of polymicrobial sepsis.
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Affiliation(s)
- S Yang
- Center for Surgical Research and Department of Surgery, Brown University School of Medicine and Rhode Island Hospital, Providence, USA
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