scholarly journals Hemodynamic Monitoring in Sepsis—A Conceptual Framework of Macro- and Microcirculatory Alterations

Diagnostics ◽  
2021 ◽  
Vol 11 (9) ◽  
pp. 1559
Author(s):  
Liana Valeanu ◽  
Serban-Ion Bubenek-Turconi ◽  
Carmen Ginghina ◽  
Cosmin Balan
Keyword(s):  
Critical Care ◽  
Fluid Resuscitation ◽  
Antimicrobial Therapy ◽  
Tissue Perfusion ◽  
Healthcare Systems ◽  
Source Control ◽  
Vasopressor Therapy ◽  
Hemodynamic Management ◽  
Hemodynamic Support ◽  
Adequate Tissue

Circulatory failure in sepsis is common and places a considerable burden on healthcare systems. It is associated with an increased likelihood of mortality, and timely recognition is a prerequisite to ensure optimum results. While there is consensus that aggressive source control, adequate antimicrobial therapy and hemodynamic management constitute crucial determinants of outcome, discussion remains about the best way to achieve each of these core principles. Sound cardiovascular support rests on tailored fluid resuscitation and vasopressor therapy. To this end, an overarching framework to improve cardiovascular dynamics has been a recurring theme in modern critical care. The object of this review is to examine the nature of one such framework that acknowledges the growing importance of adaptive hemodynamic support combining macro- and microhemodynamic variables to produce adequate tissue perfusion.

Vasopressor and Inotrope Therapy in Cardiac Critical Care

2020 ◽  
pp. 088506662091763 ◽  
Author(s):  
Jacob C. Jentzer ◽  
Steven M. Hollenberg
Keyword(s):  
Adverse Events ◽  
Arterial Pressure ◽  
Tissue Perfusion ◽  
Therapeutic Interventions ◽  
Successful Outcome ◽  
Circulatory Support ◽  
Timely Initiation ◽  
Hemodynamic Support ◽  
High Doses ◽  
Adequate Tissue

Patients admitted to the cardiac intensive care unit (CICU) are often in shock and require hemodynamic support. Identifying and addressing the pathophysiology mechanisms operating in an individual patient is crucial to achieving a successful outcome, while initiating circulatory support therapy to restore adequate tissue perfusion. Vasopressors and inotropes are the cornerstone of supportive medical therapy for shock, in addition to fluid resuscitation when indicated. Timely initiation of optimal vasopressor and inotrope therapy is essential for patients with shock, with the ultimate goals of restoring effective tissue perfusion in order to normalize cellular metabolism. Use of vasoactive agents for hemodynamic support of patients with shock should take both arterial pressure and tissue perfusion into account when choosing therapeutic interventions. For most patients with shock, including cardiogenic or septic shock, norepinephrine (NE) is an appropriate choice as a first-line vasopressor titrated to achieve an adequate arterial pressure due to a lower risk of adverse events than other catecholamine vasopressors. If tissue and organ perfusion remain inadequate, an inotrope such as dobutamine may be added to increase cardiac output to a sufficient level that meets tissue demand. Low doses of epinephrine or dopamine may be used for inotropic support, but high doses of these drugs carry an excessive risk of adverse events when used for vasopressor support and should be avoided. When NE alone is inadequate to achieve an adequate arterial pressure, addition of a noncatecholamine vasopressor such as vasopressin or angiotensin-II is reasonable, in addition to rescue therapies that may improve vasopressor responsiveness. In this review, we discuss the pharmacology and evidence-based use of vasopressor and inotrope drugs in critically ill patients, with a focus on the CICU population.

scholarly journals 216. Are Automatic Antimicrobial Stop Orders an Effective Stewardship Tool for Urinary Tract and Intra-Abdominal Infections?

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S110-S110
Author(s):  
Christina Maguire ◽  
Dusten T Rose ◽  
Theresa Jaso
Keyword(s):  
Urinary Tract ◽  
Antimicrobial Therapy ◽  
Source Control ◽  
Clostridioides Difficile ◽  
Days Of Therapy ◽  
Before And After ◽  
The Difference ◽  
Tract Infections ◽  
Length Of Therapy ◽  
The Impact

Abstract Background Automatic antimicrobial stop orders (ASOs) are a stewardship initiative used to decrease days of therapy, prevent resistance, and reduce drug costs. Limited evidence outside of the perioperative setting exists on the effects of ASOs on broad spectrum antimicrobial use, discharge prescription duration, and effects of missed doses. This study aims to evaluate the impact of an ASO policy across a health system of adult academic and community hospitals for treatment of intra-abdominal (IAI) and urinary tract infections (UTI). ASO Outcome Definitions ASO Outcomes Methods This multicenter retrospective cohort study compared patients with IAI and UTI treated before and after implementation of an ASO. Patients over the age of 18 with a diagnosis of UTI or IAI and 48 hours of intravenous (IV) antimicrobial administration were included. Patients unable to achieve IAI source control within 48 hours or those with a concomitant infection were excluded. The primary outcome was the difference in sum length of antimicrobial therapy (LOT). Secondary endpoints include length and days of antimicrobial therapy (DOT) at multiple timepoints, all cause in hospital mortality and readmission, and adverse events such as rates of Clostridioides difficile infection. Outcomes were also evaluated by type of infection, hospital site, and presence of infectious diseases (ID) pharmacist on site. Results This study included 119 patients in the pre-ASO group and 121 patients in the post-ASO group. ASO shortened sum length of therapy (LOT) (12 days vs 11 days respectively; p=0.0364) and sum DOT (15 days vs 12 days respectively; p=0.022). This finding appears to be driven by a decrease in outpatient LOT (p=0.0017) and outpatient DOT (p=0.0034). Conversely, ASO extended empiric IV LOT (p=0.005). All other secondary outcomes were not significant. Ten patients missed doses of antimicrobials due to ASO. Subgroup analyses suggested that one hospital may have influenced outcomes and reduction in LOT was observed primarily in sites without an ID pharmacist on site (p=0.018). Conclusion While implementation of ASO decreases sum length of inpatient and outpatient therapy, it may not influence inpatient length of therapy alone. Moreover, ASOs prolong use of empiric intravenous therapy. Hospitals without an ID pharmacist may benefit most from ASO protocols. Disclosures All Authors: No reported disclosures

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)

scholarly journals 379 The Critical Care Experience of Irish Surgical Non-Consultant Hospital Doctors, Are We Equipped to Assist During the Covid-19 Outbreak and Beyond?

2021 ◽  
Vol 108 (Supplement_2) ◽  
Author(s):  
E Burke ◽  
P Balfe
Keyword(s):  
Critical Care ◽  
Intensive Care ◽  
Healthcare Systems ◽  
Care Environment ◽  
Care Experience ◽  
Electronic Survey ◽  
Surgical Trainees ◽  
Hospital Doctors ◽  
Basic Course ◽  
Further Development

Abstract Introduction The ongoing COVID-19 pandemic has presented unforeseen threats and stresses to healthcare systems around the world, most notably in the ability to provide critical care. Aim To assess surgical NCHD experience in providing critical care and working in an intensive care environment. Method An electronic survey was distributed amongst surgical trainees and then amongst individual surgical departments. Ten questions were included in the survey assessing the NCHD’s experience with aspects of critical care. Results 39 respondents including 16 specialist registrars, 3 senior registrars, 11 registrars and 9 senior house officers. 18% of respondents had previous experience in anaesthetics or intensive care. 23% self-reported being competent in performing endotracheal intubation. 15% self-reported being competent in the use of CPAP and BiPaP, 5% did not know what these were. 20% self-reported being competent in the use of AIRVO. 15% self-reported being competent in placing central and arterial lines. 15% self-reported being competent in starting and adjusting inotropes/vasopressors. 49% reported completing a CCRISP or BASIC course. 85% felt that a rotation in anaesthesia should be a routine part of surgical training. Conclusions Whilst there is critical care experience amongst the surgical NCHD cohort there remains room for further development.

scholarly journals Multicountry survey of emergency and critical care medicine physicians’ fluid resuscitation practices for adult patients with early septic shock

BMJ Open ◽  
2016 ◽  
Vol 6 (7) ◽  
pp. e010041 ◽  
Author(s):  
Lauralyn McIntyre ◽  
Brian H Rowe ◽  
Timothy S Walsh ◽  
Alasdair Gray ◽  
Yaseen Arabi ◽  
...  
Keyword(s):  
Septic Shock ◽  
Critical Care ◽  
Fluid Resuscitation ◽  
Adult Patients ◽  
Critical Care Medicine

Abstract 15873: Novel Contributions of Neutrophil-derived Myeloperoxidase and Hypochlorous Acid to 20-hydroxyeicosatetraenoic Acid Production That Drives Post-ischemic Angiogenesis

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Juan A Azcona ◽  
Samantha Tang ◽  
Thomas M Jeitner ◽  
Michal Schwartzman ◽  
Austin M Guo
Keyword(s):  
Protein Expression ◽  
Hypochlorous Acid ◽  
Hypoxia Inducible Factor ◽  
Limb Ischemia ◽  
Tissue Perfusion ◽  
Underlying Mechanism ◽  
Arachidonic Acid Metabolite ◽  
Micro Vessel Density ◽  
First Time ◽  
Adequate Tissue

Introduction: Compensatory angiogenic response to ischemia is often insufficient in maintaining adequate tissue perfusion resulting in critical limb ischemia and amputation. Identifying a novel mechanism by which angiogenesis occurs in these conditions is clinically relevant. We recently uncovered that an increase in 20-HETE, an arachidonic acid metabolite of CYP4A/F ω-hydroxylases, regulates post-ischemic angiogenesis. However, the underlying mechanism resulting in this increase is unknown. Hypothesis: Neutrophil-derived myeloperoxidase (MPO) and hypochlorous acid (HOCl) critically contribute to post-ischemic 20-HETE increases that drive angiogenesis. Methods: Hindlimb ischemia was established in mice depleted of neutrophils, macrophages, and MPO (MPO -/- ). Angiogenesis was assessed by laser doppler perfusion imaging and micro-vessel density quantitation in the hindlimb gracilis muscles. MPO and HOCl were detected in these tissues using immunohistochemistry and a HOCl-specific fluorophore. We also determined the effects of MPO and HOCl on 20-HETE production, the expression of 20-HETE synthase CYP4A11, and hypoxia inducible factor-1α in cultured endothelial cells (EC) using LC/MS/MS, real time-PCR and western blot analysis, respectively. Results: We found that ischemia failed to increase 20-HETE production in mice depleted of neutrophils and MPO (13 ± 1.5 vs 35 ± 5 and ~2 ± .25 vs 35 ± 5 pg/mg of protein, respectively), accompanied with a decreased post-ischemic angiogenic phenotype. We also detected the formation of MPO and HOCl in post-ischemic gracilis muscles. MPO and HOCl also significantly stimulate CYP4A11 expression and 20-HETE production (40±12 vs 8±5 pg/mg of protein) in EC. Furthermore, HOCl quickly induces CYP4A11 mRNA/protein expression (2-fold,) and the protein expression of HIF-1α (2-fold) in as little as 15 min. Conclusion: Our studies establish for the first time that neutrophil-derived MPO and HOCl are responsible for promoting 20-HETE increases that critically drive angiogenesis post ischemia. Thus, identifying these novel mediators can further future therapeutic strategies to balance angiogenic responses during ischemia as well as treating diseases that are associated with abnormal angiogenesis.

Postoperative Vasodilatory Shock

2020 ◽  
pp. 333-342
Author(s):  
Fiona Roberts ◽  
Alan Gaffney
Keyword(s):  
Septic Shock ◽  
Cardiac Output ◽  
Fluid Resuscitation ◽  
Antimicrobial Therapy ◽  
Pulse Pressure ◽  
Vasodilatory Shock ◽  
First Line ◽  
Treatment Interventions ◽  
Common Cause ◽  
Early Fluid

This chapter discusses vasodilatory shock. The hallmark of vasodilatory shock is hypotension with normal or increased cardiac output. The hyperdynamic circulatory state of vasodilatory shock results in a tachycardia and an increased pulse pressure. Radiological and biochemical investigations can assist with determining the diagnosis of shock. The causes of vasodilatory shock are diverse; they include sepsis, surgical insult, anaphylaxis, and others such as trauma, burns, and pancreatitis. However, sepsis is by far the most common cause of vasodilatory shock. The pathophysiology of vasodilatory shock is also complex and multifactorial. Although still not fully understood, it is widely accepted that it includes activation of several intrinsic vasodilatory pathways and a vascular hyporesponsiveness to vasopressors. Early fluid resuscitation and appropriate antimicrobial therapy are the most crucial treatment interventions in septic shock. Meanwhile, noradrenaline is the first-line vasopressor of choice in septic shock.

Cardiopulmonary support in the intensive care unit

1992 ◽  
Vol 1 (1) ◽  
pp. 98-106
Author(s):  
M Cone ◽  
M Hoffman ◽  
D Jessen ◽  
P Posa ◽  
C Dailey ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Tissue Perfusion ◽  
Definitive Treatment ◽  
Critically Ill Patient ◽  
Careful Monitoring ◽  
Cardiopulmonary Support ◽  
Critical Care Team ◽  
Adequate Tissue ◽  
Cardiopulmonary Support System

The cardiopulmonary support system is an extracorporeal device that allows for rapid cardiopulmonary support of the critically ill patient in the intensive care unit. It provides immediate and complete support of cardiac and pulmonary functions to maintain perfusion to vital organs in patients who are severely physiologically compromised (eg, in cardiogenic shock, adult respiratory distress syndrome or pulmonary edema). Successful cardiopulmonary support requires systemic anticoagulation, percutaneous venous and arterial cannulation and careful monitoring by the critical care team to maintain adequate tissue perfusion and oxygenation. Although patient mortality can occur secondary to bleeding, embolism or sepsis, this technique provides life-sustaining circulatory and respiratory support until definitive treatment can be initiated.

scholarly journals 1826. Impact of Rapid Diagnostics and Ceftazidime–Avibactam on Mortality after Bacteremia Caused by Carbapenem-Resistant Enterobacteriaceae

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S41-S41
Author(s):  
Michael J Satlin ◽  
Liang Chen ◽  
Gregory Weston ◽  
Angela Gomez-Simmonds ◽  
Tanaya Bhowmick ◽  
...  
Keyword(s):  
Mortality Rate ◽  
Blood Culture ◽  
Antimicrobial Therapy ◽  
Statistical Significance ◽  
Diagnostic Methods ◽  
Source Control ◽  
Carbapenem Resistant ◽  
Carbapenemase Gene ◽  
Definitive Therapy ◽  
Carbapenem Resistant Enterobacteriaceae

Abstract Background Patients with bloodstream infections (BSIs) due to carbapenem-resistant Enterobacteriaceae (CRE) have long delays until receipt of appropriate antimicrobial therapy and high mortality rates. Rapid molecular diagnostics and novel therapies, such as ceftazidime–avibactam (CAZ-AVI), offer promise to improve outcomes, but their clinical impact is unclear. Methods We conducted an observational study of patients with CRE BSI from January 2016 to June 2018 at 8 New York and New Jersey medical centers. Patient demographics, comorbidities, clinical presentations, diagnostic methods, and treatments were compared between patients who died within 30 days of BSI onset and survivors. Independent risk factors for mortality were identified using logistic regression. We then compared time to receipt of active antimicrobial therapy between patients whose positive blood culture bottles underwent testing for the Klebsiella pneumoniae carbapenemase gene (blaKPC PCR) and patients where this test was not used. Results We identified 178 patients with CRE BSI (K. pneumoniae: n = 104, 58%; Enterobacter cloacae: n = 26, 15%; Escherichia coli: n = 26, 15%). The 30-day mortality rate was 38%. An increasing Acute Physiology and Chronic Health Evaluation II score (adjusted odds ratio [aOR] 1.06, P = 0.005) was independently associated with increased 30-day mortality; whereas, use of blaKPC PCR (aOR 0.31, P = 0.005), urinary tract source (aOR 0.12, P = 0.001), and source control (aOR 0.25, P = 0.001) were independently associated with survival. Initial targeted therapy with CAZ-AVI was associated with a 28% 30-day mortality rate, compared with a 49% 30-day mortality rate among patients who received a polymyxin or aminoglycoside (P = 0.036). Patients whose blood culture underwent blaKPC PCR were more likely to receive active antimicrobial therapy within 24 hours of BSI onset (42% vs. 28%; P = 0.07) and had a decreased median time until receipt of active therapy (25 hours vs. 46 hours; P = 0.07), although these differences did not achieve statistical significance. Conclusion The use of PCR to rapidly identify blood cultures with blaKPC and definitive therapy with CAZ-AVI instead of polymyxins or aminoglycosides were associated with decreased mortality after CRE bacteremia. Disclosures All Authors: No reported Disclosures.

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