Current use of inotropes in circulatory shock

Abstract

Background Treatment decisions on critically ill patients with circulatory shock lack consensus. In an international survey, we aimed to evaluate the indications, current practice, and therapeutic goals of inotrope therapy in the treatment of patients with circulatory shock. Methods From November 2016 to April 2017, an anonymous web-based survey on the use of cardiovascular drugs was accessible to members of the European Society of Intensive Care Medicine (ESICM). A total of 14 questions focused on the profile of respondents, the triggering factors, first-line choice, dosing, timing, targets, additional treatment strategy, and suggested effect of inotropes. In addition, a group of 42 international ESICM experts was asked to formulate recommendations for the use of inotropes based on 11 questions. Results A total of 839 physicians from 82 countries responded. Dobutamine was the first-line inotrope in critically ill patients with acute heart failure for 84% of respondents. Two-thirds of respondents (66%) stated to use inotropes when there were persistent clinical signs of hypoperfusion or persistent hyperlactatemia despite a supposed adequate use of fluids and vasopressors, with (44%) or without (22%) the context of low left ventricular ejection fraction. Nearly half (44%) of respondents stated an adequate cardiac output as target for inotropic treatment. The experts agreed on 11 strong recommendations, all of which were based on excellent (> 90%) or good (81–90%) agreement. Recommendations include the indications for inotropes (septic and cardiogenic shock), the choice of drugs (dobutamine, not dopamine), the triggers (low cardiac output and clinical signs of hypoperfusion) and targets (adequate cardiac output) and stopping criteria (adverse effects and clinical improvement). Conclusion Inotrope use in critically ill patients is quite heterogeneous as self-reported by individual caregivers. Eleven strong recommendations on the indications, choice, triggers and targets for the use of inotropes are given by international experts. Future studies should focus on consistent indications for inotrope use and implementation into a guideline for circulatory shock that encompasses individualized targets and outcomes.

An international survey of adherence to Surviving Sepsis Campaign Guidelines 2016 regarding fluid resuscitation and vasopressors in the initial management of septic shock

“…The anonymity guaranteed to the respondents promoted honest reporting. Finally, our findings validate the results of a survey conducted by Scheeren et al two years earlier [15,16]. The authors surveyed 839 clinicians using the same ESICM platform to evaluate practice and therapeutic goals regarding vasopressor use in septic shock.…”

Combination of Prehospital NT-proBNP with qSOFA and NEWS to Predict Sepsis and Sepsis-Related Mortality

“…About 25% of patients with sepsis and one-half of patients with septic shock present myocardial involvement, including biventricular thickening, diminished contractility, and diastolic dysfunction [ 60 ]. Currently, the best available treatment for myocardial dysfunction in sepsis is appropriate volume-targeted resuscitation, followed by the addition of inotropes, to ensure sufficient perfusion pressure for metabolic requirements [ 61 – 63 ].…”

Current practice and evolving concepts in septic shock resuscitation

“…Dobutamine is the inotropic agent of reference in the acutely ill patient given its clinical response and favorable onset and offset of action [24]. A limited dose of dobutamine reliably increases blood flow and microcirculatory perfusion, without significantly affecting arterial pressure [25].…”

“…Cardiomyopathy in septic shock is frequently present and whether this leads to inadequate tissue perfusion depends on the interplay between the effect of contractility and state of vasoplegia (afterload) both induced by the septic process [77]. The use of repeated echocardiography combined with clinical, hemodynamic, and biological variables is, therefore, crucial to detect, monitor and treat septic cardiomyopathy were dobutamine is the current recommended first-line inotrope for its treatment [24]. A recent study using hemodynamic profiling identified characteristics of patients with septic cardiomyopathy who might benefit from inotropic treatment [78].…”