Outcomes of patients on multiple vasoactive drugs for shock

INTRODUCTION

Vasoactive drugs are routinely used in critically ill patients with shock to optimize the hemodynamic state while evaluating and treating potentially reversible causes. Limited data exist on the use of multiple vasoactive drugs in the intensive care unit. We hypothesize that the use of 3 or more vasoactive drugs is associated with worse outcomes.

METHODS

We retrospectively examined the outcome in patients, at least 18 years of age, in whom 3 or more vasoactive drugs were administered simultaneously. We included patients admitted between November 2007 and August 2009. Vasoactive drugs included dopamine, dobutamine, epinephrine, norepinephrine, phenylephrine, and vasopressin. The primary end point was survival to hospital discharge.

RESULTS

Sixty-six patients received 3 or more vasoactive drugs simultaneously. Nine patients (14%) survived to ICU discharge and 6 patients (9%) survived to hospital discharge. There was a significant difference in mean Simplified Acute Physiology Score II between survivors (32.3 ± 28.6) and nonsurvivors (72.1 ± 30.4), P = .003. Five of the 6 survivors had an acute cardiac procedure, either percutaneous cardiac intervention or heart transplantation. The 1 patient with septic shock who survived had surgery for a bowel perforation. All patients who survived received inotropic therapy (dobutamine). None of the patients who received 4 or more vasoactive drugs survived.

CONCLUSION

Patients requiring 3 or more vasoactive drugs rarely survive in the absence of an intervention aimed at correcting the underlying cause such as revascularization or source control surgery.

Disproportionate breathlessness associated with deep sighing breathing in a patient presenting with difficult-to-treat asthma

Disproportionate breathlessness is a term that is used synonymously with dysfunctional breathing and idiopathic hyperventilation in the absence of chest disease. In the presence of chest disease, it may not be possible to use these three terms interchangeably. We report a case of a patient with documented asthma but breathlessness that was out of proportion to the measured lung function or exercise tolerance. The breathing pattern was abnormal and was characterized by the need to take frequent deep sighs, which increased in frequency during incremental exercise, despite increasing respiratory rate and tidal volume. Treatment with physiotherapist-led breathing retraining resulted in an improvement in the sigh rate and breathlessness scores. Disproportionate breathlessness and deep sighing breathing are part of the spectrum of conditions that comprise dysfunctional breathing and can cause symptoms that may be wrongly attributed to asthma.

Defining and investigating occupational asthma: a consensus approach

BACKGROUND

At present there is no internationally agreed definition of occupational asthma and there is a lack of guidance regarding the resources that should be readily available to physicians running specialist occupational asthma services.

AIMS

To agree a working definition of occupational asthma and to develop a framework of resources necessary to run a specialist occupational asthma clinic.

METHOD

A modified RAND appropriateness method was used to gain a consensus of opinion from an expert panel of clinicians running specialist occupational asthma clinics in the UK.

RESULTS

Consensus was reached over 10 terms defining occupational asthma including: occupational asthma is defined as asthma induced by exposure in the working environment to airborne dusts vapours or fumes, with or without pre-existing asthma; occupational asthma encompasses the terms "sensitiser-induced asthma" and "acute irritant-induced asthma" (reactive airways dysfunction syndrome (RADS)); acute irritant-induced asthma is a type of occupational asthma where there is no latency and no immunological sensitisation and should only be used when a single high exposure has occurred; and the term "work-related asthma" can be used to include occupational asthma, acute irritant-induced asthma (RADS) and aggravation of pre-existing asthma. Disagreement arose on whether low dose irritant-induced asthma existed, but the panel agreed that if it did exist they would include it in the definition of "work-related asthma". The panel agreed on a set of 18 resources which should be available to a specialist occupational asthma service. These included pre-bronchodilator FEV1 and FVC (% predicted); peak flow monitoring (and plotting of results, OASYS II analysis); non-specific provocation challenge in the laboratory and specific IgE to a wide variety of occupational agents.

CONCLUSION

It is hoped that the outcome of this process will improve uniformity of definition and investigation of occupational asthma across the UK.

Defining and investigating difficult asthma: developing quality indicators

BACKGROUND

There is no agreed definition of 'difficult asthma' or what investigations should be available to investigate these patients. Patients with difficult asthma remain symptomatic on high levels of treatment and are high users of medical resources.

AIM

To develop a set of quality indicators for the definition and investigation of difficult asthma.

METHOD

Modified RAND Appropriateness Method was used. An expert panel composed of nine hospital asthma specialists who run 'difficult' asthma clinics and were identified from a short list of key workers in the field. Indicators were rated as necessary to define and investigate difficult asthma.

RESULTS

Difficult asthma was defined as 'symptoms persisting beyond therapy consistent with step 4 of the British Thoracic Society (BTS) guidelines' (high dose inhaled corticosteroids and long acting beta(2)-agonists). Eighty-three indicators were identified (40 relating to definition and 43 relating to investigations). Of these 32 (39%) were rated as necessary: 7 out of 40 (18%) for defining difficult asthma and 23 out of 43 (53%) for investigations. Indicators of high medical resource usage were characteristic of the 'difficult' nature of the management of patient with difficult asthma. A framework for the investigation of these patients was created.

CONCLUSION

The listed performance indicators identify a range of requirements that are necessary to define difficult asthma. Targeting of real needs in this group of patients will lead to better patient care and reduction of 'waste' in provision of healthcare.