Vasopressors in shock: are we meeting our target and do we really understand what we are aiming at?

Dünser, Martin W.; Hjortrup, Peter Buhl; Pettilä, Ville

doi:10.1007/s00134-016-4269-8

Cited by 12 publications

(3 citation statements)

References 15 publications

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“… 1 In the setting of hypovolaemic shock, they are sometimes used as bridge therapy until an intervention targeting the source of the problem can be implemented. 2 For example, during the early phase of resuscitation following trauma, vasopressors can maintain a minimal perfusion pressure without exposing patients to large volumes of intravenous fluid. 3–7 Early fluid administration, be it from massive transfusions or crystalloid administration, can lead to life-threatening complications such as trauma-induced coagulopathy.…”

Section: Introductionmentioning

confidence: 99%

Early vasopressor use following traumatic injury: a systematic review

et al. 2017

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ObjectivesCurrent guidelines suggest limiting the use of vasopressors following traumatic injury; however, wide variations in practice exist. Although excessive vasoconstriction may be harmful, these agents may help reduce administration of potentially harmful resuscitation fluids. This systematic review aims to compare early vasopressor use to standard resuscitation in adults with trauma-induced shock.DesignSystematic review.Data sourcesWe searched MEDLINE, EMBASE, ClinicalTrials.gov and the Central Register of Controlled Trials from inception until October 2016, as well as the proceedings of 10 relevant international conferences from 2005 to 2016.Eligibility criteria for selecting studiesRandomised controlled trials and controlled observational studies that compared the early vasopressor use with standard resuscitation in adults with acute traumatic injury.ResultsOf 8001 citations, we retrieved 18 full-text articles and included 6 studies (1 randomised controlled trial and 5 observational studies), including 2 published exclusively in abstract form. Across observational studies, vasopressor use was associated with increased short-term mortality, with unadjusted risk ratios ranging from 2.31 to 7.39. However, the risk of bias was considered high in these observational studies because patients who received vasopressors were systematically sicker than patients treated without vasopressors. One clinical trial (n=78) was too imprecise to yield meaningful results. Two clinical trials are currently ongoing. No study measured long-term quality of life or cognitive function.ConclusionsExisting data on the effects of vasopressors following traumatic injury are of very low quality according to the Grading of Recommendations, Assessment, Development and Evaluation methodology. With emerging evidence of harm associated with aggressive fluid resuscitation and, in selected subgroups of patients, with permissive hypotension, the alternatives to vasopressor therapy are limited. Observational data showing that vasopressors are part of usual care would provide a strong justification for high-quality clinical trials of early vasopressor use during trauma resuscitation.Trial registration number CRD42016033437.

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Section: Introductionmentioning

confidence: 99%

Early vasopressor use following traumatic injury: a systematic review

et al. 2017

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“…For example, if a MAP target is 75 mmHg, then the use of PVI is likely to be higher than if the target was 65 mmHg. This is an ongoing area of contention in critical care and peri-operative medicine (Dünser et al 2016 ; Futier et al 2017 ). A history of pre-existing cardiac disease may require higher MAP targets.…”

Section: Discussionmentioning

confidence: 99%

The need for post-operative vasopressor infusions after major gynae-oncologic surgery within an ERAS (Enhanced Recovery After Surgery) pathway

et al. 2020

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Background Hypotension following major abdominal surgery is common, and once hypovolaemia has been optimally treated, is often due to vasodilation which can be treated with vasopressor infusions. There is unpredictability in the dose and duration of post-operative vasopressor infusions, and factors associated with this have not been determined. Methods We present a case series of consecutive patients who received major gynae-oncology surgery delivered within an Enhanced Recovery After Surgery (ERAS) pathway at a single institution. Patients were electively admitted from theatre directly to the intensive care unit (ICU). Data was collected prospectively into electronic databases (Philips ICCA, Wardwatcher) and then retrospectively collated and appropriate statistical analyses were performed. In the absence of a consensus definition of vasoplegia, we, necessarily arbitrarily, chose a noradrenaline dose of > 0.1 mcg/kg/min at 08:00 on the first post-operative day. The rationale is that this would be more than would typically be expected to counteract the vasodilatory effects of epidural analgesia, which is commonly used at our institution. Results Data was collected from 324 patients, all treated between February 2014 and July 2016. The average age was 67 years and 39% received neoadjuvant chemotherapy. The commonest tumour type was ovarian (58%). The median estimated blood loss was 800 ml and epidural analgesia was used in 71%. Fifty per cent received post-operative vasopressor infusions: factors associated with this included epidural use and estimated blood loss. Nineteen per cent met our criteria for vasoplegia: factors associated with this included CRP on post-operative day 1 and P-POSSUM morbidity score. Hospital and ICU length of stay was prolonged in those who had vasoplegia. Conclusions Patients commonly receive vasopressors following major gynae-oncologic surgery, and this can be at relatively high doses. Clinical factors only accounted for a minority of the variability in vasopressor usage—suggesting considerable biological variability. Optimal care of patients having major abdomino-pelvic surgery may include advanced haemodynamic monitoring and ready availability of infused vasopressors, in a suitable environment.

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“…При титровании вазопрессоров по целевому среднему артериальному давлению зоной комфорта для САД является его уровень от 70 до 85 мм рт.ст. (Sepsis Pamtrial) [9]. Уделяется большое внимание динами-ке ЦВД и его влиянию на венозный возврат и сер-дечный выброс (P.E.…”

Section: в табл 2 представлены фазы инфузионной тера-пии (Ea Hosteunclassified

Сепсис: Традиції Та Інновації В Термінології, Патогенезі, Діагностиці, Інтенсивній Терапії — Заради Врятування Та Збереження Життя Хворого

Мосенцев¹,

Lisnichaya²,

Базиленко³

et al. 2022

ЕМ

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У статті висвітлено нові позиції, що стосуються визначень сепсису, септичного шоку, життєзагрозливої органної дисфункції; представлена система SOFA. Показано, що нові визначення сепсису не виключають синдрому системної запальної відповіді. Виділені головні пріоритети в діагностиці та інтенсивній терапії сепсису. Висвітлена стратегія фазового перебігу септичного шоку: SOSD. Надані фактори ризику та їх трактування в шкалах SRS і SSRS. Викладено основні позиції нової парадигми патогенезу сепсису, засновані на послідовному включенні в патофізіологічні механізми певних біомаркерів. Дана характеристика фазового перебігу шоку залежно від принципу, мети, часу прояву, інфузійної терапії, типового сценарію результату захворювання, даних моніторингу. Обґрунтовано принципи діагностики гіповолемії, гіпергідратації. Наведено аналіз впливу значень центрального венозного тиску на серцевий викид, гостре пошкодження нирок, мікроциркуляцію. Оцінено фактори ризику і результату за часом розрішення септичного шоку при різних стратегіях інфузійної терапії. Виявлено переваги та недоліки ліберальної і консервативної оксигенації. Встановлено доцільність імунокорекції. Доведено, що високе співвідношення P(v-a) CO2/C(a-v)O2 є індикатором анаеробного метаболізму, а інтрамукозний ацидоз відображає спланхничну гіпоперфузію. Надані варіанти метаболічної ресусцитації.

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Vasopressors in shock: are we meeting our target and do we really understand what we are aiming at?

Cited by 12 publications

References 15 publications

Early vasopressor use following traumatic injury: a systematic review

Early vasopressor use following traumatic injury: a systematic review

The need for post-operative vasopressor infusions after major gynae-oncologic surgery within an ERAS (Enhanced Recovery After Surgery) pathway

Сепсис: Традиції Та Інновації В Термінології, Патогенезі, Діагностиці, Інтенсивній Терапії — Заради Врятування Та Збереження Життя Хворого

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