Update on Vasopressors and Inotropes in Septic Shock

2002 ◽  
Vol 15 (2) ◽  
pp. 124-134 ◽  
Author(s):  
Maria I. Rudis ◽  
Clarence Chant
Keyword(s):  
Septic Shock ◽  
Oxygen Transport ◽  
Young Patients ◽  
Tissue Perfusion ◽  
Splanchnic Circulation ◽  
Oxygen Extraction Ratio ◽  
Goal Directed Therapy ◽  
Hemodynamic Variables ◽  
Refractory Hypotension ◽  
Splanchnic Oxygen

Vasopressors and inotropes are used in septic shock in patients who remain hypotensive despite adequate fluid resuscitation. The goal is to increase blood pressure to optimize perfusion to organs. Generally, goal-directed therapy to supra-normal oxygen transport variables cannot be recommended due to lack of benefit. Traditionally, vasopressors and inotropes in septic shock have been started in a step-wise fashion starting with dopamine. Recent data suggest that there may be true differences among vasopressors and inotropes on local tissue perfusion as measured by regional hemodynamic and oxygen transport. When started early in septic shock, norepinephrine decreases mortality, optimizes hemodynamic variables, and improves systemic and regional (eg, renal, gastric mucosal, splanchnic) perfusion. Epinephrine causes a greater increase in cardiac index (CI) and oxygen delivery (DO2 ) and increases gastric mucosal flow, but increases lactic acid and may not adequately preserve splanchnic circulation owing to its predominant vasoconstrictive alpha (α ) effects. Epinephrine may be particularly useful when used earlier in the course of septic shock in young patients and those who do not have any known cardiac abnormalities. Unlike epinephrine, dopamine does not preferentially increase the proportion of CI that preferentially goes to the splanchnic circulation. Dopamine is further limited because it cannot increase CI by more than 35% and is accompanied by tachycardia or tachydysrhythmias. Dopamine, as opposed to norepinephrine, may worsen splanchnic oxygen consumption (VO2 ) and oxygen extraction ratio (O2 ER). Low-dose dopamine has not been shown to consistently increase the glomerular filtration rate or prevent renal failure, and, indeed, worsens splanchnic tissue oxygen use. Routine use of concurrently administered dopamine with vasopressors is not recommended. Phenylephrine should be used when a pure vasoconstrictor is desired in patients who may not require or do not tolerate the beta (β ) effects of dopamine or norepinephrine with or without dobutamine. Patients with high filling pressure and hypotension may benefit from the combination of phenylephrine and dobutamine. Investigational approaches to vasopressor-refractory hypotension in septic shock include the use of vasopressin and corticosteroids.

Modification of Oxygen Extraction Ratio by Change in Oxygen Transport in Septic Shock

CHEST Journal ◽  
1992 ◽  
Vol 102 (1) ◽  
pp. 221-226 ◽  
Author(s):  
Marc Wysocki ◽  
Mohamed Besbes ◽  
Eric Roupie ◽  
Christian Brun-Buisson
Keyword(s):  
Septic Shock ◽  
Oxygen Transport ◽  
Extraction Ratio ◽  
Oxygen Extraction ◽  
Oxygen Extraction Ratio

Oxygen Transport Goals in the Resuscitation of Critically Ill Patients

1994 ◽  
Vol 28 (11) ◽  
pp. 1273-1284 ◽  
Author(s):  
Joseph F. Dasta ◽  
Brian L. Erstad
Keyword(s):  
Septic Shock ◽  
Critically Ill ◽  
Oxygen Transport ◽  
Critically Ill Patients ◽  
Data Extraction ◽  
Hypovolemic Shock ◽  
Tissue Perfusion ◽  
Therapeutic Interventions ◽  
Monitoring Techniques ◽  
Review Articles

OBJECTIVE: To discuss the limitations of conventional monitoring techniques of shock and examine more recent monitoring techniques that are used to titrate therapies to attain supranormal oxygen transport goals. DATA SOURCES: Review articles and investigations published since 1973. STUDY SELECTION: Articles were selected if they examined the monitoring or treatment of shock. Emphasis was placed on finding investigations involving humans that used innovative methods to assess and treat inadequate tissue perfusion. DATA EXTRACTION: Data were extracted primarily from original investigations and review articles published in or translated into English. DATA SYNTHESIS: The conventional monitoring of shock often fails to detect inadequate tissue perfusion, which may lead to inadequate resuscitation of patients, resulting in increased morbidity and mortality. Attainment of supranormal values for oxygen transport variables has been associated with improved outcomes, especially in patients with hypovolemic shock or septic shock. Additionally, interventions used to increase these variables to supranormal values have resulted in improved survival in high-risk preoperative patients with hypovolemic or septic shock, but not in severely ill postoperative patients with multiple complications. CONCLUSIONS: Efforts to increase oxygen transport variables to supranormal values cannot be recommended routinely for all critically ill patients. Preoperative patients in early stages of hypovolemic or septic shock may benefit from therapies titrated to achieve supranormal goals, but patients in later stages of illnesses may be harmed by such attempts. Questions remain regarding how quickly and how long the oxygen transport variables should be elevated. The most effective and least toxic therapeutic interventions for increasing the variables need to be determined.

scholarly journals Effect of early goal directed therapy on tissue perfusion in patients with septic shock

2013 ◽  
Vol 4 (2) ◽  
pp. 117 ◽  
Author(s):  
Yuan-hua Lu ◽  
Ling Liu ◽  
Xiao-hua Qiu ◽  
Qin Yu ◽  
Yi Yang ◽  
...  
Keyword(s):  
Septic Shock ◽  
Tissue Perfusion ◽  
Goal Directed Therapy ◽  
Early Goal Directed Therapy

scholarly journals Oxygen Tissue Saturation Is Lower in Nonsurvivors than in Survivors after Early Resuscitation of Septic Shock

2009 ◽  
Vol 111 (2) ◽  
pp. 366-371 ◽  
Author(s):  
Marc Leone ◽  
Sami Blidi ◽  
François Antonini ◽  
Bertrand Meyssignac ◽  
Sébastien Bordon ◽  
...  
Keyword(s):  
Septic Shock ◽  
Oxygen Saturation ◽  
Tissue Oxygenation ◽  
Microvascular Dysfunction ◽  
Tissue Oxygen Saturation ◽  
Tissue Oxygen ◽  
Goal Directed Therapy ◽  
Early Goal Directed Therapy ◽  
Hemodynamic Variables ◽  
Central Venous Saturation

Background Growing evidence suggests that the microvascular dysfunction is the key element of the pathogenesis of septic shock. This study's purpose was to explore whether the outcome of septic shock patients after early resuscitation using early goal-directed therapy is related to their muscle tissue oxygenation. Methods Tissue oxygen saturation (Sto2) was monitored in septic shock patients using a tissue spectrometer (InSpectra Model 325; Hutchinson Technology, Hutchinson, MN). For the purpose of this retrospective study, the Sto2 values were collected at the first measurement done after the macrohemodynamic variables (mean arterial pressure, urine output, central venous saturation in oxygen) were optimized. Results After the hemodynamic variables were corrected, no difference was observed between the nonsurvivors and survivors, with the exception of pulse oximetry saturation (94% [92-97%] vs. 97% [94-99%], P = 0.04). The Sto2 values were significantly lower in the nonsurvivors than in the survivors (73% [68-82%] vs. 84% [81-90%], P = 0.02). No correlations were found between the Sto2 and Spo2 (P = 0.7). Conclusions In septic shock patients, tissue oxygen saturation below 78% is associated with increased mortality at day 28. Further investigations are required to determine whether the correction of an impaired level of tissue oxygen saturation may improve the outcome of these patients.

scholarly journals Effects of capillary refill time-vs. lactate-targeted fluid resuscitation on regional, microcirculatory and hypoxia-related perfusion parameters in septic shock: a randomized controlled trial

2020 ◽  
Vol 10 (1) ◽  
Author(s):  
Ricardo Castro ◽  
Eduardo Kattan ◽  
Giorgio Ferri ◽  
Ronald Pairumani ◽  
Emilio Daniel Valenzuela ◽  
...  
Keyword(s):  
Septic Shock ◽  
Randomized Controlled Trial ◽  
Fluid Resuscitation ◽  
Controlled Trial ◽  
Tissue Perfusion ◽  
Capillary Refill Time ◽  
Capillary Refill ◽  
Randomized Controlled ◽  
Microcirculatory Flow ◽  
The Impact

Abstract Background Persistent hyperlactatemia has been considered as a signal of tissue hypoperfusion in septic shock patients, but multiple non-hypoperfusion-related pathogenic mechanisms could be involved. Therefore, pursuing lactate normalization may lead to the risk of fluid overload. Peripheral perfusion, assessed by the capillary refill time (CRT), could be an effective alternative resuscitation target as recently demonstrated by the ANDROMEDA-SHOCK trial. We designed the present randomized controlled trial to address the impact of a CRT-targeted (CRT-T) vs. a lactate-targeted (LAC-T) fluid resuscitation strategy on fluid balances within 24 h of septic shock diagnosis. In addition, we compared the effects of both strategies on organ dysfunction, regional and microcirculatory flow, and tissue hypoxia surrogates. Results Forty-two fluid-responsive septic shock patients were randomized into CRT-T or LAC-T groups. Fluids were administered until target achievement during the 6 h intervention period, or until safety criteria were met. CRT-T was aimed at CRT normalization (≤ 3 s), whereas in LAC-T the goal was lactate normalization (≤ 2 mmol/L) or a 20% decrease every 2 h. Multimodal perfusion monitoring included sublingual microcirculatory assessment; plasma-disappearance rate of indocyanine green; muscle oxygen saturation; central venous-arterial pCO2 gradient/ arterial-venous O2 content difference ratio; and lactate/pyruvate ratio. There was no difference between CRT-T vs. LAC-T in 6 h-fluid boluses (875 [375–2625] vs. 1500 [1000–2000], p = 0.3), or balances (982[249–2833] vs. 15,800 [740–6587, p = 0.2]). CRT-T was associated with a higher achievement of the predefined perfusion target (62 vs. 24, p = 0.03). No significant differences in perfusion-related variables or hypoxia surrogates were observed. Conclusions CRT-targeted fluid resuscitation was not superior to a lactate-targeted one on fluid administration or balances. However, it was associated with comparable effects on regional and microcirculatory flow parameters and hypoxia surrogates, and a faster achievement of the predefined resuscitation target. Our data suggest that stopping fluids in patients with CRT ≤ 3 s appears as safe in terms of tissue perfusion. Clinical Trials: ClinicalTrials.gov Identifier: NCT03762005 (Retrospectively registered on December 3rd 2018)

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