Impact of Norepinephrine Weight-Based Dosing Compared With Non–Weight-Based Dosing in Achieving Time to Goal Mean Arterial Pressure in Obese Patients With Septic Shock

2016 ◽  
Vol 51 (3) ◽  
pp. 194-202 ◽  
Author(s):  
Nina Vadiei ◽  
Mitchell J. Daley ◽  
Manasa S. Murthy ◽  
Carrie S. Shuman
Keyword(s):  
Septic Shock ◽  
Mean Arterial Pressure ◽  
Arterial Pressure ◽  
Primary Outcome ◽  
Obese Patients ◽  
First Line ◽  
Multicenter Cohort Study ◽  
Multicenter Cohort ◽  
Norepinephrine Dose ◽  
Goal Map

Background: Currently, a lack of standardization exists in norepinephrine dosing units, the first-line vasopressor for septic shock. Timely achievement of goal mean arterial pressure (MAP) is dependent on optimal vasopressor dosing. Objective: To determine if weight-based dosing (WBD) of norepinephrine leads to earlier time to goal MAP compared with non-WBD in obese patients with septic shock. Methods: This was a retrospective, multicenter cohort study. Patients had a body mass index (BMI) ≥30 kg/m2 and received norepinephrine for septic shock with either a non-WBD strategy (between December 2009 and January 2013) or WBD strategy (between January 2013 and December 2015). The primary outcome was time to goal MAP. Secondary outcomes were norepinephrine duration, dose requirements, and development of treatment-related complications. Results: A total of 287 patients were included (WBD 144; non-WBD 143). There was no difference in median time to goal MAP (WBD 58 minutes, interquartile range [IQR] = 16.8-118.5, vs non-WBD 60 minutes, IQR = 17.5-193.5; P = 0.28). However, there was a difference in median cumulative norepinephrine dose (WBD 12.6 mg, IQR = 4.9-45.9, vs non-WBD 10.5 mg, IQR = 3.9-25.6; P = 0.04) and time to norepinephrine discontinuation (WBD 33 hours, IQR = 15-69, vs non-WBD 27 hours, IQR = 12-51; P = 0.03). There was no difference in rates of atrial fibrillation (WBD 15.3% vs non-WBD 23.7%; P = 0.07) or mortality (WBD 23.6% vs non-WBD 23.1%; P = 0.92). Conclusion: WBD of norepinephrine does not achieve time to goal MAP earlier in obese patients with septic shock. However, WBD may lead to higher norepinephrine cumulative dose requirements and prolonged time until norepinephrine discontinuation.

Norepinephrine Dosing in Obese and Nonobese Patients With Septic Shock

2016 ◽  
Vol 25 (1) ◽  
pp. 27-32 ◽  
Author(s):  
John J. Radosevich ◽  
Asad E. Patanwala ◽  
Brian L. Erstad
Keyword(s):  
Body Mass Index ◽  
Septic Shock ◽  
Mean Arterial Pressure ◽  
Arterial Pressure ◽  
Body Mass ◽  
Secondary Outcome ◽  
Obese Patients ◽  
Hemodynamic Status ◽  
Norepinephrine Infusion ◽  
Nonobese Patients

Background Whether or not norepinephrine infusions for support of hemodynamic status in patients with septic shock should be weight based is unknown. This situation is particularly pertinent in patients who are extremely overweight or obese. Objective To compare dosing requirements and effect of norepinephrine on blood pressure in obese and nonobese patients with septic shock. Methods In a retrospective cohort study, data on adult patients with septic shock who received norepinephrine infusion for support of hemodynamic status in a tertiary care, academic medical center were analyzed. Patients were categorized as obese (body mass index ≥ 30) or nonobese (body mass index < 30). The primary outcome was dosing requirements of norepinephrine at 60 minutes after the start of the infusion. The secondary outcome was the log-transformed ratio of mean arterial pressure to norepinephrine. Results The final cohort consisted of 100 obese and 100 nonobese patients. Mean norepinephrine infusion rate at 60 minutes was 0.09 (SD, 0.08) μg/kg per minute in the obese group and 0.13 (SD, 0.14) μg/kg per minute in the nonobese group (P = .006). The non–weight-based dose at 60 minutes was 9 μg/min in obese patients and 8 μg/min in nonobese patients (P = .72). The log transformed mean arterial pressure to norepinephrine ratio at 60 minutes was 2.5 (SD, 0.9) in obese patients and 2.5 (SD, 0.8) in nonobese patients (P = .54) Conclusions Compared with nonobese patients, obese patients with septic shock require lower weight-based doses of norepinephrine and similar total norepinephrine doses.

scholarly journals Clinical characteristics, sepsis interventions and outcomes in the obese patients with septic shock: an international multicenter cohort study

Critical Care ◽  
2013 ◽  
Vol 17 (2) ◽  
pp. R72 ◽  
Author(s):  
Yaseen M Arabi ◽  
Saqib I Dara ◽  
Hani M Tamim ◽  
Asgar H Rishu ◽  
Abderrezak Bouchama ◽  
...  
Keyword(s):  
Septic Shock ◽  
Cohort Study ◽  
Clinical Characteristics ◽  
Obese Patients ◽  
Multicenter Cohort Study ◽  
Multicenter Cohort ◽  
International Multicenter

Efficacy and Safety of the Early Addition of Vasopressin to Norepinephrine in Septic Shock

2017 ◽  
Vol 34 (11-12) ◽  
pp. 910-916 ◽  
Author(s):  
Drayton A. Hammond ◽  
Julia Cullen ◽  
Jacob T. Painter ◽  
Kelsey McCain ◽  
Oktawia A. Clem ◽  
...  
Keyword(s):  
Septic Shock ◽  
Mean Arterial Pressure ◽  
Arterial Pressure ◽  
Early Initiation ◽  
Shock Onset ◽  
Kaplan Meier ◽  
Wilcoxon Rank Sum Test ◽  
Failure Assessment ◽  
Goal Map ◽  
Reduced Time

Background: Delays in achievement of target mean arterial pressure (MAP) have been associated with increased mortality in patients with septic shock. Vasopressin may be added to norepinephrine to raise MAP or decrease norepinephrine dosage. The purpose of this study was to determine whether early initiation of vasopressin to norepinephrine resulted in a reduced time to target MAP compared to norepinephrine monotherapy. Methods: This retrospective cohort study compared early addition of vasopressin within 4 hours of septic shock onset to norepinephrine versus initial norepinephrine monotherapy in medically, critically ill patients with septic shock admitted from May 2014 to October 2015. Time to goal MAP was compared using Student t test and examined with Kaplan-Meier curves. Changes in Sequential Organ Failure Assessment (SOFA) scores were evaluated with Wilcoxon rank sum test. Results: Each group contained 48 patients. Mean arterial pressure (61.5 vs 58.6 mm Hg) and intravenous fluid volume received at vasopressor initiation (14.3 vs 25.2 hours, P = .014) were similar. Patients started on early vasopressin achieved and maintained goal MAP sooner (6.2 vs 9.9 hours, P = .023), experienced greater reductions in SOFA scores at 72 hours (−4 vs −1, P = .012), and had shorter hospital durations (343 vs 604 hours, P = .014). Not initiating early vasopressin trended toward an association with increased time to goal MAP ( P = .067). Conclusion: Early initiation of vasopressin in patients with septic shock may achieve and maintain goal MAP sooner and resolve organ dysfunction at 72 hours more effectively than later or no initiation.

scholarly journals Efficacy of 4-hour rescue therapeutic plasma exchange in severe septic shock patients

2020 ◽  
Vol 58 (2) ◽  
pp. 75-80
Author(s):  
Rabab Mahmoud Ahmed ◽  
Amin R. Soliman ◽  
Ahmad Yousry ◽  
Khaled Marzouk ◽  
Farouk Faris
Keyword(s):  
Septic Shock ◽  
Mean Arterial Pressure ◽  
Arterial Pressure ◽  
Plasma Exchange ◽  
Case Series ◽  
Early Initiation ◽  
Therapeutic Plasma Exchange ◽  
Case Series Study ◽  
Norepinephrine Dose ◽  
Severe Septic Shock

AbstractBackground.Early intervention for septic shock is crucial to reduce mortality and improve outcome. There is still a great debate over the exact time of therapeutic plasma exchange (TPE) administration in septic shock patients. This study aims to investigate the effect of early initiation (within 4 hours) of TPE in severe septic shock on hemodynamics & outcome.Methods. We conducted a prospective, before-after case series study on 16 septic shock patients requiring high doses of vasopressors admitted in two ICUs from Cairo, Egypt. All of our patients received TPE within 4 hours of ICU admission. The fresh frozen plasma exchange volume = 1.5 × plasma volume.Results. In the 16 patients included in the study, mean arterial pressure was significantly improved after the initial TPE (p < 0.002) and norepinephrine dose which significantly reduced post TPE (p < 0.001). In addition, norepinephrine dose to mean arterial pressure significantly improved (p < 0.001). There was reduction of a net 6 hours fluid balances following the first TPE were observed in all the patients (p < 0.03) by a mean of 757 ml. Systemic vascular resistance index was markedly improved post-TPE along with statistically improved cardiac index (p < 0.01). Stroke volume variance was also significantly decreased after the TPE sessions (p < 0.01). C-reactive protein significantly improved after TPE (P < 0.01).Conclusion. Early initiation of TPE in severe septic shock patients might improve hemodynamic measures.

Effect of Vasopressin Dose on Hemodynamic Response in Obese Patients With Septic Shock: A Retrospective Observational Study

2021 ◽  
pp. 106002802110072
Author(s):  
Casey A. Dubrawka ◽  
Kevin D. Betthauser ◽  
Hannah E. Pope ◽  
Gabrielle A. Gibson
Keyword(s):  
Septic Shock ◽  
Retrospective Cohort ◽  
Primary Outcome ◽  
Standard Dose ◽  
Hemodynamic Response ◽  
Percentage Change ◽  
High Dose ◽  
Obese Patients ◽  
Improved Outcomes ◽  
Higher Doses

Background No clear association between standard vasopressin doses and body mass index exists, despite potential pharmacokinetic and pharmacodynamic variability among patients with septic shock. It is unknown if higher doses may alter hemodynamic response. Objective The purpose of this study was to evaluate the effect of vasopressin dose on hemodynamic response in obese patients with septic shock. Methods A single-center, retrospective cohort study was conducted in adult, obese patients with septic shock receiving catecholamine vasopressors and vasopressin. Patients were analyzed according to vasopressin dose received: standard dose (≤0.04 U/min) and high dose (>0.04 U/min). The primary outcome was percentage change in norepinephrine equivalent (NEQ) dose. Results A total of 182 patients were included in the analysis, with 136 in the standard-dose vasopressin group and 46 in the high-dose vasopressin group. There was no difference in percentage change in NEQ dose at 6 hours after standard- or high-dose vasopressin attainment (−28.6% vs −19.1%; P = 0.166). A greater increase in mean arterial pressure (MAP) at 6 hours was observed with receipt of high-dose vasopressin (23.3% vs 15.3%; P = 0.023). Duration of shock and length of stay were significantly longer in patients who received high-dose vasopressin, with no difference in in-hospital mortality. Conclusion and Relevance This represents the first analysis comparing standard and higher doses of vasopressin in obese patients with septic shock. Receipt of high-dose vasopressin was not associated with a difference in catecholamine requirement or improved outcomes. Further studies are warranted to provide guidance on the use of high-dose vasopressin in septic shock.

Pharmacological modulation of procoagulant microparticles improves haemodynamic dysfunction during septic shock in rats

2014 ◽  
Vol 111 (01) ◽  
pp. 154-164 ◽  
Author(s):  
Su-Emmanuelle Degirmenci ◽  
Fatiha Zobairi ◽  
Asael Berger ◽  
Grégory Meyer ◽  
Mélanie Burban ◽  
...  
Keyword(s):  
Septic Shock ◽  
Mean Arterial Pressure ◽  
Arterial Pressure ◽  
Vascular Dysfunction ◽  
Vascular Inflammation ◽  
Activated Protein C ◽  
Resistance Arteries ◽  
Pharmacological Modulation ◽  
Circulating Microparticles ◽  
Haemodynamic Improvement

SummaryCirculating microparticles play a pro-inflammatory and procoagulant detrimental role in the vascular dysfunction of septic shock. It was the objective of this study to investigate mechanisms by which a pharmacological modulation of microparticles could affect vascular dysfunction in a rat model of septic shock. Septic or sham rats were treated by activated protein C (aPC) and resuscitated during 4 hours. Their microparticles were harvested and inoculated to another set of healthy recipient rats. Haemodynamic parameters were monitored, circulating total procoagulant microparticles assessed by prothrombinase assay, and their cell origin characterised. Mesenteric resistance arteries, aorta and heart were harvested for western blotting analysis. We found that a) the amount and phenotype of circulating microparticles were altered in septic rats with an enhanced endothelial, leucocyte and platelet contribution; b) aPC treatment significantly reduced the generation of leucocyte microparticles and norepinephrine requirements to reach the mean arterial pressure target in septic rats; c) Microparticles from untreated septic rats, but not from aPC-treated ones, significantly reduced the healthy recipients’ mean arterial pressure; d) Microparticle thromboxane content and aPC activity were significantly increased in aPC-treated septic rats. In inoculated naïve recipients, microparticles from aPC-treated septic rats prompted reduced NF-κB and cyclooxygenase-2 arterial activation, blunted the generation of pro-inflammatory iNOS and secondarily increased platelet and endothelial microparticles. In conclusion, in this septic shock model, increased circulating levels of procoagulant microparticles led to negative haemodynamic outcomes. Pharmacological treatment by aPC modified the cell origin and levels of circulating microparticles, thereby limiting vascular inflammation and favouring haemodynamic improvement.

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