Is the Sympathetic System Detrimental in the Setting of Septic Shock, with Antihypertensive Agents as a Counterintuitive Approach? A Clinical Proposition

Mortality in the setting of septic shock varies between 20% and 100%. Refractory septic shock leads to early circulatory failure and carries the worst prognosis. The pathophysiology is poorly understood despite studies of the microcirculatory defects and the immuno-paralysis. The acute circulatory distress is treated with volume expansion, administration of vasopressors (usually noradrenaline: NA), and inotropes. Ventilation and anti-infectious strategy shall not be discussed here. When circulation is considered, the literature is segregated between interventions directed to the systemic circulation vs. interventions directed to the micro-circulation. Our thesis is that, after stabilization of the acute cardioventilatory distress, the prolonged sympathetic hyperactivity is detrimental in the setting of septic shock. Our hypothesis is that the sympathetic hyperactivity observed in septic shock being normalized towards baseline activity will improve the microcirculation by recoupling the capillaries and the systemic circulation. Therefore, counterintuitively, antihypertensive agents such as beta-blockers or alpha-2 adrenergic agonists (clonidine, dexmedetomidine) are useful. They would reduce the noradrenaline requirements. Adjuncts (vitamins, steroids, NO donors/inhibitors, etc.) proposed to normalize the sepsis-evoked vasodilation are not reviewed. This itemized approach (systemic vs. microcirculation) requires physiological and epidemiological studies to look for reduced mortality.

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Study on the Efficacy and Timing of ECMO Therapy in Children With Refractory Septic Shock

Case Medical Research ◽

10.31525/ct1-nct03948048 ◽

2019 ◽

Author(s):

Keyword(s):

Septic Shock ◽

Refractory Septic Shock ◽

Ecmo Therapy

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Cerebral fat embolization with paroxysmal sympathetic hyperactivity syndrome and septic shock at high altitude: a case report and literature review

Chinese Neurosurgical Journal ◽

10.1186/s41016-021-00232-6 ◽

2021 ◽

Vol 7 (1) ◽

Author(s):

Min Li ◽

Gang Zhu ◽

Hao Guo ◽

Shun Nan Ge ◽

Guo Dong Gao ◽

...

Keyword(s):

Septic Shock ◽

Differential Diagnosis ◽

Case Report ◽

Literature Review ◽

High Altitude ◽

Fat Embolism ◽

Neurological Rehabilitation ◽

Case Presentation ◽

Sympathetic Hyperactivity ◽

Paroxysmal Sympathetic Hyperactivity

AbstractBackgroundCerebral fat embolism (CFE) syndrome at high altitude was rare complicated with paroxysmal sympathetic hyperactivity (PSH) syndrome and septic shock. It is a challenge to differential diagnosis and treatment at high altitude.Case presentationThis case presents a CFE with PSH and septic shock of a 23-year-old man occurred at high altitude of 3800 m above sea level, transferred by airplane successfully and cured in the department of neurosurgery, Xi’an Tangdu Hospital.ConclusionsIt is key that CFE with PSH can be rapid diagnosed and treatment bundles of septic shock should be initiated as soon as possible. Early neurological rehabilitation played an important role for good outcome.

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Validation of the pediatric refractory septic shock definition: post hoc analysis of a controlled trial

Annals of Intensive Care ◽

10.1186/s13613-021-00822-8 ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Luc Morin ◽

Karthik Narayanan Ramaswamy ◽

Muralidharan Jayashree ◽

Arun Bansal ◽

Karthi Nallasamy ◽

...

Keyword(s):

Septic Shock ◽

Intensive Care ◽

Neonatal Intensive Care ◽

Controlled Trial ◽

Receiver Operating Curve ◽

Double Blind ◽

Post Hoc Analysis ◽

Prognostic Accuracy ◽

Refractory Septic Shock ◽

Post Hoc

Abstract Background The European Society of Pediatric and Neonatal Intensive Care (ESPNIC) developed and validated a definition of pediatric refractory septic shock (RSS), based on two septic shock scores (SSS). Both bedside SSS (bSSS) and computed SSS (cSSS) were found to be strongly associated with mortality. We aimed at assessing the accuracy of the RSS definition on a prospective cohort from India. Methods Post hoc analysis of a cohort issued from a double-blind randomized trial that compared first-line vasoactive drugs in children with septic shock. Sequential bSSS and cSSS from 60 children (single-center study, 53% mortality) were analyzed. The prognostic value of the ESPNIC RSS definition was tested for 28-day all-cause mortality. Results In this septic shock cohort, RSS was diagnosed in 35 patients (58.3%) during the first 24 h. Death occurred in 30 RSS patients (85.7% mortality) and in 2 non-RSS patients (8% mortality), OR = 60.9 [95% CI: 10.5–676.2], p < 0.001 with a median delay from sepsis onset of 3 days [1.0–6.7]. Among patients diagnosed with RSS, the mortality was not significantly different according to vasopressors randomization. Diagnosis of RSS with bSSS and cSSS had a high discrimination for death with an area under the receiver operating curve of 0.916 [95% CI: 0.843–0.990] and 0.925 [95% CI: 0.845–1.000], respectively. High prognostic accuracy of the bSSS was found in the first hours following intensive care admission. The best interval of prognostication occurs after the 12th hour following treatment initiation (AUC 0.973 [95% CI: 0.925–1.000]). Conclusions The ESPNIC refractory septic shock definition accurately identifies, within the first 6 h of septic shock management, children with lethal outcome.

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Venoarterial extracorporeal membrane oxygenation as mechanical circulatory support in adult septic shock: a systematic review and meta-analysis with individual participant data meta-regression analysis

Critical Care ◽

10.1186/s13054-021-03668-5 ◽

2021 ◽

Vol 25 (1) ◽

Author(s):

Ryan Ruiyang Ling ◽

Kollengode Ramanathan ◽

Wynne Hsing Poon ◽

Chuen Seng Tan ◽

Nicolas Brechot ◽

...

Keyword(s):

Septic Shock ◽

Extracorporeal Membrane Oxygenation ◽

Mechanical Circulatory Support ◽

Meta Analysis ◽

Left Ventricular ◽

Adult Patients ◽

Circulatory Support ◽

Venoarterial Extracorporeal Membrane Oxygenation ◽

Refractory Septic Shock ◽

Va Ecmo

Abstract Background While recommended by international societal guidelines in the paediatric population, the use of venoarterial extracorporeal membrane oxygenation (VA ECMO) as mechanical circulatory support for refractory septic shock in adults is controversial. We aimed to characterise the outcomes of adults with septic shock requiring VA ECMO, and identify factors associated with survival. Methods We searched Pubmed, Embase, Scopus and Cochrane databases from inception until 1st June 2021, and included all relevant publications reporting on > 5 adult patients requiring VA ECMO for septic shock. Study quality and certainty in evidence were assessed using the appropriate Joanna Briggs Institute checklist, and the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach, respectively. The primary outcome was survival to hospital discharge, and secondary outcomes included intensive care unit length of stay, duration of ECMO support, complications while on ECMO, and sources of sepsis. Random-effects meta-analysis (DerSimonian and Laird) were conducted. Data synthesis We included 14 observational studies with 468 patients in the meta-analysis. Pooled survival was 36.4% (95% confidence interval [CI]: 23.6%–50.1%). Survival among patients with left ventricular ejection fraction (LVEF) < 20% (62.0%, 95%-CI: 51.6%–72.0%) was significantly higher than those with LVEF > 35% (32.1%, 95%-CI: 8.69%–60.7%, p = 0.05). Survival reported in studies from Asia (19.5%, 95%-CI: 13.0%–26.8%) was notably lower than those from Europe (61.0%, 95%-CI: 48.4%–73.0%) and North America (45.5%, 95%-CI: 16.7%–75.8%). GRADE assessment indicated high certainty of evidence for pooled survival. Conclusions When treated with VA ECMO, the majority of patients with septic shock and severe sepsis-induced myocardial depression survive. However, VA ECMO has poor outcomes in adults with septic shock without severe left ventricular depression. VA ECMO may be a viable treatment option in carefully selected adult patients with refractory septic shock.

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P88 Paroxysmal sympathetic storm and the role of beta-blockers in traumatic brain injury: a scoping review protocol

BJS Open ◽

10.1093/bjsopen/zrab032.087 ◽

2021 ◽

Vol 5 (Supplement_1) ◽

Author(s):

Stéphane Nguembu ◽

Marco Meloni ◽

Geneviève Endalle ◽

Hugues Dokponou ◽

Olaoluwa Ezekiel Dada ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Length Of Stay ◽

Glasgow Coma Scale ◽

Scoping Review ◽

Beta Blockers ◽

Clinical Signs ◽

Sympathetic Hyperactivity ◽

Paroxysmal Sympathetic Hyperactivity

Abstract Introduction Most cases of paroxysmal sympathetic hyperactivity (PSH) result from traumatic brain injury (TBI). Little is known about its pathophysiology and treatment, and several neuroprotective drugs are used including beta-blockers. The aim of our study is to collate existing evidence of the role of beta-blockers in the treatment of PSH. Method We will search MEDLINE, Web of Science, EMBASE, Cochrane, and Google Scholar. The search terms used will cover the following terms: “paroxysmal sympathetic hyperactivity”, “traumatic brain injury” and “beta-blockers.”: No language or geographical restrictions will be applied. Two independent co-authors will screen the titles and abstracts of each article following predefined inclusion and exclusion criteria. If there is a conflict the two reviewers will find a consensus and if they cannot a third co-author will decide. Using a pre-designed and pre-piloted data extraction form, data from each included citation will be collected (authors identification, study type, TBI severity, type of beta-blockers used, dosage of the drug, clinical signs of PSH, Glasgow Coma Scale, Glasgow Outcome Scale, mortality, morbidity and length of stay). Simple descriptive data analyses will be performed and the results will be presented both in a narrative and tabular form. Results The effectiveness of beta-blockers in post-TBI PHS will be evaluated through clinical signs of PHS(increased heart rate, respiratory rate, temperature, blood pressure, and sweating), Glasgow Coma Scale, and Glasgow Outcome Scale. mortality, morbidity and length of stay. Conclusion At the end of this scoping review we will design a systematic review with metaanalysis if there are a reasonable number of studies otherwise we will design a randomized controlled trial.

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Venoarterial extracorporeal membrane oxygenation support for neonatal and pediatric refractory septic shock: more than 15 years of learning

European Journal of Pediatrics ◽

10.1007/s00431-018-3174-2 ◽

2018 ◽

Vol 177 (8) ◽

pp. 1191-1200 ◽

Cited By ~ 10

Author(s):

Anna Solé ◽

Iolanda Jordan ◽

Sara Bobillo ◽

Julio Moreno ◽

Monica Balaguer ◽

...

Keyword(s):

Septic Shock ◽

Extracorporeal Membrane Oxygenation ◽

Membrane Oxygenation ◽

Venoarterial Extracorporeal Membrane Oxygenation ◽

Refractory Septic Shock

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“All In” For a Huge Pot: The PROWESS-SHOCK Trial for Refractory Septic Shock

Surgical Infections ◽

10.1089/sur.2007.9980 ◽

2007 ◽

Vol 8 (5) ◽

pp. 491-494 ◽

Cited By ~ 15

Author(s):

Philip S. Barie

Keyword(s):

Septic Shock ◽

Shock Trial ◽

Refractory Septic Shock

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Improving the therapy of generalized forms of Meningococcal infection in children using extracorporeal hemocorrection

CHILDREN INFECTIONS ◽

10.22627/2072-8107-2021-20-2-49-56 ◽

2021 ◽

Vol 20 (2) ◽

pp. 49-56

Author(s):

K. V. Markova ◽

E. Yu. Skripchenko ◽

K. V. Serednyakov ◽

Yu. V. Lobzin ◽

N. V. Skripchenko ◽

...

Keyword(s):

Septic Shock ◽

Multiple Organ Failure ◽

Organ Failure ◽

Multiple Organ ◽

Meningococcal Infection ◽

Basic Drug ◽

Inflammatory Reactions ◽

Clinical Center ◽

Refractory Septic Shock ◽

Group 2

Invasive meningococcal infection is a significant cause of death, reaching 80% in septic shock. The Pediatric Research and Clinical Center for Infectious Diseases (PRCCID) has developed an algorithm for the treatment of children with invasive meningococcal infection with refractory septic shock and multiple organ failure syndrome, which includes basic drug therapy with polymyxin hemoperfusion in combination with extended methods of extracorporeal hemocorrection.Purpose: to evaluate the effectiveness of extracorporeal hemocorrection operations in children with invasive meningococcal infection with refractory septic shock and multiple organ failure syndrome.Materials and research methods: to the intensive care unit of the PRCCID for the analyzed period 2006—2020 34 children were hospitalized with invasive meningococcal infection with refractory septic shock and multiple organ failure syndrome. Two groups were formed: Group 1 — children admitted to the PRCCID in the period 2014—2020 (n = 23), who underwent polymyxin hemoperfusion simultaneously with extended methods of extracorporeal hemocorrection, group 2 — children hospitalized in 2006—201 3 (n = 1 1), methods of extracorporeal hemocorrection were not performed. The Mann-Whitney U-test and ANOVA were used to evaluate the results.Results and discussion: the use of extracorporeal hemocorrection operations in the complex therapy of invasive forms of meningococcal infection with refractory septic shock and multiple organ failure syndrome in children provides stabilization of central hemodynamics, reduces clinical and laboratory inflammatory reactions, helps to reduce the dose of vasopressor drugs and parameters of respiratory support, and also increases patient survival rate by 82.6%.

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