cardiovascular-agents and Shock--Septic

Methylene blue (MB) has received much attention in the perioperative and critical care literature because of its ability to antagonize the profound vasodilation seen in distributive (also referred to as vasodilatory or vasoplegic) shock states. This review will discuss the pharmacologic properties of MB and review the critical care, liver transplantation, and cardiac anesthesia literature with respect to the efficacy and safety of MB for the treatment of shock. Although improved blood pressure has consistently been demonstrated with the use of MB in small trials and case reports, better oxygen delivery or decreased mortality with MB use has not been demonstrated. Large randomized controlled trials are still necessary to identify the role of MB in hemodynamic resuscitation of the critically ill.

Topics: Cardiac Surgical Procedures; Cardiovascular Agents; Hemodynamics; Humans; Liver Transplantation; Methylene Blue; Resuscitation; Shock, Septic; Treatment Outcome; Vasodilation; Vasoplegia

To systematically review randomized controlled trials (RCTs) of steroids conducted in children with fluid and/or vasoactive medication-dependent shock and evaluate and report on the quality and clinical and methodological heterogeneity of included trials.. MEDLINE (1946 to January Week 2, 2012), Embase (1947-January 20, 2012), Cochrane Central Register of Controlled Trials (through January 2012), and reference lists of retrieved publications. No language restrictions were applied.. We included only RCTs reporting on steroid use and clinical outcomes in pediatric shock.. Study characteristics, interventions, and outcomes were retrieved by three independent reviewers. Pooled relative risks and 95% CIs were calculated using a random effects model.. We identified 535 citations from which 13 full-text articles were retrieved for assessment. Eight articles evaluating a total of 447 children were selected for review. The median trial size was 67 patients (range, 28-98). Seven of the eight trials were published prior to 1996, and all trials were conducted in the developing world, and six of eight trials were in the setting of dengue shock. We found methodological issues related to allocation concealment, blinding and reporting of co-interventions, and outcome data among the included trials along with varying types, doses, timings, and duration of steroids making it difficult to compare outcomes. The overall meta-analysis showed no difference in mortality rates between those who did and did not receive steroids (relative risks, 0.744 [95% CI, 0.475-1.165]; p = 0.197).. The literature on the use of steroids in pediatric shock is limited in amount and methodological quality and demonstrates conflicting results. The limited evidence on which current guidelines are based strongly supports the need for a well-designed, pragmatic randomized controlled trial on the use of steroids in pediatric shock to inform future guidelines.

Topics: Adrenal Cortex Hormones; Cardiovascular Agents; Child; Fluid Therapy; Humans; Intensive Care Units, Pediatric; Randomized Controlled Trials as Topic; Shock, Septic

Severe sepsis and septic shock are as common and lethal as other acute life-threatening conditions that emergency physicians routinely confront such as acute myocardial infarction, stroke, and trauma. Recent studies have led to a better understanding of the pathogenic mechanisms and the development of new or newly applied therapies. These therapies place early and aggressive management of severe sepsis and septic shock as integral to improving outcome. This independent review of the literature examines the recent pathogenic, diagnostic, and therapeutic advances in severe sepsis and septic shock for adults, with particular relevance to emergency practice. Recommendations are provided for therapies that have been shown to improve outcomes, including early goal-directed therapy, early and appropriate antimicrobials, source control, recombinant human activated protein C, corticosteroids, and low tidal volume mechanical ventilation.

Topics: Adrenal Cortex Hormones; Algorithms; Anti-Bacterial Agents; Cardiovascular Agents; Drug Therapy, Combination; Humans; Practice Guidelines as Topic; Protein C; Recombinant Proteins; Respiration, Artificial; Sepsis; Shock, Septic

Shock is one of the most frequent situations encountered in the intensive care unit (ICU). Important new concepts have emerged for shock management in recent years. The concept of early goal-directed therapy has evolved from the basic management concepts for septic shock delivered in a structured fashion. Numerous cardiovascular techniques, methods, and strategies have been developed as novel alternatives to the use of the pulmonary artery catheter. Among these techniques, echocardiography, esophageal Doppler, and arterial pulse contour analysis show great promise. Prediction of responsiveness to fluid administration is a key component of the management of shock, as is assessing cardiovascular performance. The intensive care physician has several options to evaluate and treat shock. Further research should yield additional important advances.

Topics: Cardiovascular Agents; Echocardiography, Doppler; Fluid Therapy; Humans; Intensive Care Units; Monitoring, Physiologic; Shock; Shock, Septic

Topics: Acute Kidney Injury; Blood Coagulation Disorders; Cardiovascular Agents; Humans; Infections; Shock, Septic

Topics: Adjuvants, Immunologic; Cardiovascular Agents; Fluid Therapy; Humans; Infection Control; Intensive Care Units; Respiration, Artificial; Resuscitation; Sepsis; Shock, Septic

The controversy surrounding the use of the pulmonary artery catheter, has stimulated research into alternative methods of haemodynamic monitoring. As yet, however, no new gold standard has emerged. In the future, interest in haemodynamic monitoring is likely to focus more on tissue perfusion and metabolism instead of central circulation. Important causes of shock in the ICU, apart from acute blood loss, are sepsis and acute heart failure. Septic shock results from vasodilatation and myocardial dysfunction. Early initiation of aggressive fluid resuscitation, if necessary accompanied by vasoactive and inotropic agents, improves survival. In addition, low dose corticosteroids have a positive impact on mortality. In the treatment of patients with acute heart failure, phosphodiesterase III-inhibitors are becoming part of standard therapy in addition to beta-adrenoceptor agonists, especially in patients who take beta-blockers.

Topics: 3',5'-Cyclic-AMP Phosphodiesterases; Adrenal Cortex Hormones; Adrenergic beta-Agonists; Cardiotonic Agents; Cardiovascular Agents; Cyclic Nucleotide Phosphodiesterases, Type 3; Fluid Therapy; Heart Arrest; Hemodynamics; Humans; Intensive Care Units; Monitoring, Physiologic; Perfusion; Phosphodiesterase Inhibitors; Shock; Shock, Septic

Yangambin was initially selected from a number of lignans isolated from Brazilian plants for its ability to antagonize Platelet-Activating Factor (PAF, 1-O-hexadecyl-2-acetyl- sn-glyceryl-3-phosphorylcholine)-induced biological effects. Subsequently it was shown that, besides its antagonistic properties at PAF receptors, yangambin also prevents the cardiovascular collapse observed during anaphylactic and endotoxic/septic shocks, as well as the vascular and cardiac hyporesponsiveness to catecholamines in endotoxic shock. It is suggested that this naturally occurring compound could be of potential interest in the adjunctive management of the above mentioned pathologies. In the present article, we review the main studies investigating the pharmacological properties of yangambin related to the cardiovascular function.

Topics: Anaphylaxis; Animals; Blood Platelets; Cardiovascular Agents; Furans; Hemodynamics; In Vitro Techniques; Lignans; Plant Extracts; Platelet Activating Factor; Platelet Aggregation Inhibitors; Platelet Membrane Glycoproteins; Receptors, Cell Surface; Receptors, G-Protein-Coupled; Shock, Septic; Stereoisomerism

Topics: Cardiovascular Agents; Combined Modality Therapy; Critical Care; Heart Failure; Hemodynamics; Humans; Monitoring, Physiologic; Oxygen; Shock, Septic

Septic shock is a common emergency, most often caused by gram-negative bacteremia. Appearance of gram-negative endotoxin in the systemic circulation sets off a complex reaction involving many physiologic systems. The resultant reduction in microcirculation and subsequent organ dysfunction often lead to death. Early therapy to support the cardiovascular system and rational antibiotic therapy may improve the chance of survival. Careful monitoring of disease and drug effect parameters is essential to therapy.

Topics: Adrenal Cortex Hormones; Anti-Bacterial Agents; Cardiovascular Agents; Humans; Risk; Shock, Septic

Topics: Acidosis; Adrenal Cortex Hormones; Arteriovenous Anastomosis; Blood Coagulation Disorders; Blood Transfusion; Cardiovascular Agents; Child; Child, Preschool; Hemodynamics; Hormones; Humans; Hypoxia; Infant; Infant, Newborn; Microcirculation; Receptors, Adrenergic; Shock; Shock, Hemorrhagic; Shock, Septic

Septic shock has a 90-day mortality risk of up to 50 %. The hemodynamic targets, including mean arterial pressure (MAP) are not based on robust clinical data. Both severe hypotension and high doses of vasopressors may be harmful. Hence, re-evaluation of hemodynamic targets in septic shock is relevant.. The targeted tissue perfusion versus macrocirculation-guided standard care in patients with septic shock (TARTARE-2S) trial is a prospective, two-parallel-group, randomized, open-label, multicenter trial with assessor-blinded outcome evaluation. We will randomize at least 200 patients with septic shock in four European intensive care units (ICUs) to test whether a tissue perfusion-guided treatment strategy based on capillary refill time, peripheral temperature, arterial lactate concentrations, and accepting lower MAP levels, leads to a faster resolution of shock than macrocirculation target-guided standard care. The primary outcome measure is days alive in 30 days with normal arterial blood lactate (first value of <2 mmol/L) and without any inotropic or vasopressor agent. Secondary outcomes include individual components of the primary outcome, days alive without renal replacement, days alive without mechanical ventilation in 30 days, and new acute kidney injury. The sample size enables detection of a 13.5-h difference in the primary outcome with a type 1 error of 5 % and power of 80 %, assuming 25 % mortality and a mean of 650 h (SD 30) among the 30-day survivors. After 150 included patients the statistician masked for allocation group will recalculate the sample size potentially increasing the sample up to 300. The Data Safety and Monitoring Board (DSMB) will review the safety data after 100 patients.. The TARTARE-2S trial will provide important clinical data on treatment targets in septic shock, evaluating the impact of clinical tissue perfusion-guided hemodynamic treatment on a surrogate outcome combining resolution of shock (hyperlactatemia and vasopressors/inotropes), and 30-day mortality.. ClinicalTrials.gov: NCT02579525 . Registered on 19 October 2015.

Topics: Arterial Pressure; Biomarkers; Cardiotonic Agents; Cardiovascular Agents; Clinical Protocols; Combined Modality Therapy; Data Interpretation, Statistical; Europe; Feasibility Studies; Fluid Therapy; Hemodynamics; Humans; Lactic Acid; Microcirculation; Models, Statistical; Prospective Studies; Regional Blood Flow; Renal Replacement Therapy; Research Design; Respiration, Artificial; Sample Size; Shock, Septic; Time Factors; Treatment Outcome; Vasoconstrictor Agents

Goal-directed therapy has been used for severe sepsis and septic shock in the intensive care unit. This approach involves adjustments of cardiac preload, afterload, and contractility to balance oxygen delivery with oxygen demand. The purpose of this study was to evaluate the efficacy of early goal-directed therapy before admission to the intensive care unit.. We randomly assigned patients who arrived at an urban emergency department with severe sepsis or septic shock to receive either six hours of early goal-directed therapy or standard therapy (as a control) before admission to the intensive care unit. Clinicians who subsequently assumed the care of the patients were blinded to the treatment assignment. In-hospital mortality (the primary efficacy outcome), end points with respect to resuscitation, and Acute Physiology and Chronic Health Evaluation (APACHE II) scores were obtained serially for 72 hours and compared between the study groups.. Of the 263 enrolled patients, 130 were randomly assigned to early goal-directed therapy and 133 to standard therapy; there were no significant differences between the groups with respect to base-line characteristics. In-hospital mortality was 30.5 percent in the group assigned to early goal-directed therapy, as compared with 46.5 percent in the group assigned to standard therapy (P = 0.009). During the interval from 7 to 72 hours, the patients assigned to early goal-directed therapy had a significantly higher mean (+/-SD) central venous oxygen saturation (70.4+/-10.7 percent vs. 65.3+/-11.4 percent), a lower lactate concentration (3.0+/-4.4 vs. 3.9+/-4.4 mmol per liter), a lower base deficit (2.0+/-6.6 vs. 5.1+/-6.7 mmol per liter), and a higher pH (7.40+/-0.12 vs. 7.36+/-0.12) than the patients assigned to standard therapy (P < or = 0.02 for all comparisons). During the same period, mean APACHE II scores were significantly lower, indicating less severe organ dysfunction, in the patients assigned to early goal-directed therapy than in those assigned to standard therapy (13.0+/-6.3 vs. 15.9+/-6.4, P < 0.001).. Early goal-directed therapy provides significant benefits with respect to outcome in patients with severe sepsis and septic shock.

Topics: Aged; Algorithms; APACHE; Blood Pressure; Cardiovascular Agents; Emergency Service, Hospital; Erythrocyte Transfusion; Female; Fluid Therapy; Health Resources; Hemodynamics; Hospital Mortality; Hospitals, Urban; Humans; Male; Middle Aged; Monitoring, Physiologic; Oxygen; Prospective Studies; Sepsis; Shock, Septic; Single-Blind Method; Systemic Inflammatory Response Syndrome; Treatment Outcome

Based on the pathogenesis of infectious shock which were stagnation of Qi, blood stasis, impairment of body resistance and trends to collapse, a series of new preparations of traditional Chinese Medicine was developed, Injection Kangjue Tongmai, Injection Yiqi Jiuyin and Injection Yiqi Huiyang, which could Liqi Huoxue and Kaibi Gutuo (regulate the flow of Qi, promote blood circulation, strengthen the body resistance and remit collapse), the result of 183 cases of infectious shock treated with them showed that the mortality was 4.37%, significantly lower than that of control group (23.0%). All three injections could rapidly elevate blood pressure and stabilize it for prolonged time, increase renal blood flow and lower blood viscosity. In animal experiment, the injections reduced lipid peroxide of vital organs, stabilized bio-membrane, protected the cell structure and maintained their normal functions.

Topics: Adult; Aged; Animals; Blood Pressure; Blood Viscosity; Cardiovascular Agents; Diagnosis, Differential; Drugs, Chinese Herbal; Female; Humans; Lipid Peroxides; Male; Medicine, Chinese Traditional; Middle Aged; Rabbits; Renal Circulation; Shock, Septic

Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. As such, circulating cytokines and danger- and pathogen-associated molecular patterns (such as endotoxins) are recognized as central in the pathogenesis of sepsis and organ dysfunction. Removing these compounds by extracorporeal blood filtration, commonly considered blood purification, may improve the septic patients' condition. This study aimed to assess the vaso-inotropic support evolution over time in pediatric patients with vasoplegic shock treated with oXiris©.. All patients aged below 18 years admitted at the Paris Saclay University Quaternary Pediatric Intensive Care Unit with vasoplegic shock and acute kidney injury and treated with oXiris© between October 2017 and January 2020 were included. The vaso-inotropic score and the 28-day mortality were assessed. Improvement under treatment was defined as a 50% decrease in the vaso-inotropic score following 24 h of oXiris© therapy.. Eleven pediatric patients aged 2-15 years and weighing 11-60 kg were admitted with vasoplegic shock and acute kidney injury. They received thirteen sessions of oXiris© therapy for septic shock (N = 7) and liver failure (N = 6). Eight patients did not improve their condition during the session, and five ultimately died (37.5% survival). Five patients improved, decreasing their inotropic support by >50% in 24 h. Among them, four survived (80%).. Hemofiltration and extracorporeal blood purification with oXiris© can be used in pediatric patients with vasoplegic shock with rapid improvement in hemodynamics in selected patients.

Topics: Acute Kidney Injury; Adolescent; Cardiovascular Agents; Child; Child, Preschool; Critical Illness; Humans; Multiple Organ Failure; Sepsis; Shock, Septic

Topics: Aged; Aged, 80 and over; Biomarkers; Cardiovascular Agents; Cardiovascular Diseases; Critical Illness; Female; Hospital Mortality; Humans; Length of Stay; Male; Middle Aged; Prospective Studies; Respiration, Artificial; Risk Factors; Shock, Septic; Symptom Assessment; Troponin I

The American College of Critical Care Medicine provided 2002 and 2007 guidelines for hemodynamic support of newborn and pediatric septic shock. Provide the 2014 update of the 2007 American College of Critical Care Medicine "Clinical Guidelines for Hemodynamic Support of Neonates and Children with Septic Shock.". Society of Critical Care Medicine members were identified from general solicitation at Society of Critical Care Medicine Educational and Scientific Symposia (2006-2014). The PubMed/Medline/Embase literature (2006-14) was searched by the Society of Critical Care Medicine librarian using the keywords: sepsis, septicemia, septic shock, endotoxemia, persistent pulmonary hypertension, nitric oxide, extracorporeal membrane oxygenation, and American College of Critical Care Medicine guidelines in the newborn and pediatric age groups.. The 2002 and 2007 guidelines were widely disseminated, translated into Spanish and Portuguese, and incorporated into Society of Critical Care Medicine and American Heart Association/Pediatric Advanced Life Support sanctioned recommendations. The review of new literature highlights two tertiary pediatric centers that implemented quality improvement initiatives to improve early septic shock recognition and first-hour compliance to these guidelines. Improved compliance reduced hospital mortality from 4% to 2%. Analysis of Global Sepsis Initiative data in resource rich developed and developing nations further showed improved hospital mortality with compliance to first-hour and stabilization guideline recommendations.. The major new recommendation in the 2014 update is consideration of institution-specific use of 1) a "recognition bundle" containing a trigger tool for rapid identification of patients with septic shock, 2) a "resuscitation and stabilization bundle" to help adherence to best practice principles, and 3) a "performance bundle" to identify and overcome perceived barriers to the pursuit of best practice principles.

Topics: Anesthesia; Biomarkers; Cardiovascular Agents; Child; Critical Care; Extracorporeal Membrane Oxygenation; Fluid Therapy; Hemodynamics; Hospital Mortality; Humans; Infant, Newborn; Monitoring, Physiologic; Patient Care Bundles; Practice Guidelines as Topic; Resuscitation; Shock, Septic; Time Factors; United States

To compare the hemodynamic response in septic shock patients receiving vasopressin who were on chronic renin-angiotensin-aldosterone system inhibitor therapy with those who were not.. Single-center, retrospective cohort study.. Medical and surgical ICUs at a 1,100-bed academic medical center.. Medical and surgical ICU patients with septic shock who received vasopressin infusion added to at least one concomitant vasopressor agent between January 2014 and December 2015, then divided into two cohorts: 1) patients who were on chronic renin-angiotensin-aldosterone system inhibitor therapy as outpatients and 2) patients who were not on chronic renin-angiotensin-aldosterone system inhibitor therapy as outpatients.. None.. Mean arterial pressure at 6 hours was 72.2 mm Hg in the renin-angiotensin-aldosterone system inhibitor group versus 69.7 mm Hg in the non-renin-angiotensin-aldosterone system inhibitor group (p = 0.298). There was no difference in mean arterial pressure at 1, 24, or 48 hours between groups. Total concomitant vasopressor requirements, based on norepinephrine equivalents excluding vasopressin, were significantly lower at 24 hours in the renin-angiotensin-aldosterone system inhibitor group versus the non-renin-angiotensin-aldosterone system inhibitor group (10.7 vs 18.1 µg/min, respectively; p = 0.007), but no significant differences were seen at the other time points assessed. There were no significant differences in ICU or hospital length of stay or mortality.. There was no significant difference in the primary outcome of 6-hour mean arterial pressure in septic shock patients receiving vasopressin who were on chronic renin-angiotensin-aldosterone system inhibitor therapy versus those receiving vasopressin who were not on chronic renin-angiotensin-aldosterone system inhibitor therapy. Renin-angiotensin-aldosterone system inhibitor patients had lower total concomitant vasopressor requirements at 24 hours compared with non-renin-angiotensin-aldosterone system inhibitor patients.

Topics: Academic Medical Centers; Adult; Aged; Aged, 80 and over; Angiotensin Receptor Antagonists; Angiotensin-Converting Enzyme Inhibitors; Blood Pressure; Cardiovascular Agents; Dose-Response Relationship, Drug; Female; Hospital Mortality; Humans; Infusions, Intravenous; Length of Stay; Male; Middle Aged; Renin-Angiotensin System; Retrospective Studies; Shock, Septic; Vasoconstrictor Agents; Vasopressins

Previous studies have suggested that lowering heart rate (HR) by selective β1-blockers improves sepsis-induced cardiac and vascular dysfunction primarily by decreasing proinflammatory pathways. However, the impact of isolated heart rate reduction (HRR) on hemodynamics and inflammatory pathways remains unknown. The present study was designed to assess the effects of HRR by ivabradine, an If channel inhibitor, on cardiovascular function and inflammatory pathways in peritonitis-induced septic shock in rats.. Randomized animal study.. University research laboratory.. Four hours after cecal ligation and puncture (CLP), Wistar rats were randomly allocated to the following groups: CLP (n = 8) and CLP + ivabradine (n = 8, administered per os 4 h after the surgery). Another eight Wistar male rats underwent sham operation. All rats received a continuous infusion of saline (10 mL kg h), analgesic (nalbuphine: 0.2 mg kg h), and antibiotics (imipenem and cilastatin sodium: 10 mg kg) 4 h after the surgery. Assessment at 18 h included hemodynamics, in vivo cardiac function by echocardiography, and ex vivo vasoreactivity by myography. Circulating cytokine levels (TNF-α, IL-6, and IL-10) were measured by ELISA, whereas cardiac and vascular protein expressions of NF-κB/IκBα/iNOS and Akt/eNOS were assessed by Western blotting.. Compared with sham animals, CLP induced tachycardia, hypotension, decreased cardiac output, hyperlactatemia, and vascular hyporesponsiveness to vasopressors. Compared with the CLP group, adjunction of ivabradine decreased the HR without any impact on blood pressure, lactatemia, or vascular responsiveness to vasopressors. Adjunction of ivabradine to CLP rats had no impact on TNF-α, IL-6, and IL-10 cytokines, or on the protein expression levels of phosphorylated forms of NF-κB, Akt, eNOS, and degradation of IκBα in cardiac and vascular tissues.. Isolated HRR by ivabradine in an experimental model of septic shock does not appear to be associated with any effect on the tested parameters of cardiac function or on vascular responsiveness to vasopressors. Moreover, in this setting, ivabradine does not alter the circulating levels of selected pro/anti-inflammatory cytokines or cardiac and vascular NF-κB/IκBα protein expression levels.

Topics: Animals; Benzazepines; Cardiovascular Agents; Cecum; Echocardiography; Heart Rate; Hemodynamics; Interleukin-10; Interleukin-6; Ivabradine; Ligation; Male; Rats; Rats, Wistar; Shock, Septic; Tumor Necrosis Factor-alpha

This research is aimed to discover the influence and underling mechanism of combined infusion of arginine vasopressin with levosimendan on acute lung injury in rat septic shock with norepinephrine supplemented. The traditional fecal peritonitis-induced septic shock model was undergone in rats for study. It is observed that the combined infusion supplemented with norepinephrine brought about a lower mean pulmonary artery pressure; lower high-mobility group box 1 levels, pulmonary levels of interleukin-6, and arterial total nitrate/nitrite; lower apoptotic cells scores and total histological scores; but higher pulmonary gas exchange when compared with the separate infusion group and norepinephrine group. This therapy shows potential clinical beneficial assistance in sepsis-induced acute lung injury. The results suggest the mechanism of such effect is through abating pulmonary artery pressure, and more importantly suppressing inflammatory responses in lung when compared with norepinephrine infusion group and the separate infusion of levosimendan or vasopressin alone.

Topics: Acute Lung Injury; Animals; Blood Gas Analysis; Cardiovascular Agents; Cytokines; Disease Models, Animal; Drug Therapy, Combination; Female; HMGB1 Protein; Hydrazones; Lung; Nitrogen Oxides; Norepinephrine; Pyridazines; Rats; Shock, Septic; Simendan; Vasopressins

Limited evidence exists on the use of corticosteroids in pediatric shock. We sought to determine physicians' practices and beliefs with regard to the management of pediatric shock.. Cross-sectional, Internet-based survey.. Canada.. Physicians identified as practicing pediatric intensive care in any of 15 academic centers.. Seventy of 97 physicians (72.2%) responded. Physicians stated that they were more likely to prescribe steroids for septic shock than for shock following cardiac surgery (odds ratio, 1.9 [95% CI, 0.9-4.3]) or trauma (odds ratio, 11.46 [95% CI, 2.5-51.2]), and 91.4% (64/70) would administer steroids to patients who had received 60 cc/kg of fluid and two or more vasoactive medications. Thirty-five percent of respondents (25/70) reported that they rarely or never conducted adrenal axis testing before giving steroids to patients in shock. Eighty-seven percent of respondents (61/70) stated that the role of steroids in the treatment of fluid and/or vasoactive drug-dependent shock needed to be clarified and that 84.3% would be willing to randomize patients into a trial of steroid efficacy who were fluid resuscitated and on one high-dose vasoactive medication. However, 74.3% stated that they would start open-label steroids in patients who required two high-dose vasoactive medications.. This survey provides information on the stated beliefs and practices of pediatric critical care physicians with regard to the use of steroids in fluid and/or vasoactive drug-dependent shock. Clinicians feel that the role of steroids in shock still requires clarification and that they would be willing to randomize patients into a trial. This survey may be useful as an initial framework for the development of a future trial on the use of steroids in pediatric shock.

Topics: Adrenal Cortex Function Tests; Adrenal Cortex Hormones; Attitude of Health Personnel; Canada; Cardiovascular Agents; Child; Cross-Sectional Studies; Fluid Therapy; Humans; Intensive Care Units, Pediatric; Practice Patterns, Physicians'; Randomized Controlled Trials as Topic; Shock, Septic; Surveys and Questionnaires

Topics: Adrenal Cortex Hormones; Attitude of Health Personnel; Cardiovascular Agents; Fluid Therapy; Humans; Practice Patterns, Physicians'; Shock, Septic

The objective of this study was to determine the effects of a TREM (triggering receptor expressed on myeloid cells 1)-like transcript 1-derived peptide (LR12) administration during septic shock in pigs. Two hours after induction of a fecal peritonitis, anesthetized and mechanically ventilated adult male minipigs were randomized to receive LR12 (n = 6) or its vehicle alone (normal saline, n = 5). Two animals were operated and instrumented without the induction of peritonitis and served as controls (sham). Resuscitation was achieved using hydroxyethyl starch (up to 20 mL/kg) and norepinephrine infusion (up to 10 μg/kg per minute). Hemodynamic parameters were continuously recorded. Gas exchange, acid-base status, organ function, and plasma cytokines concentrations were evaluated at regular intervals until 24 h after the onset of peritonitis when animals were killed under anesthesia. Peritonitis induced profound hypotension, myocardial dysfunction, lactic acidosis, coagulation abnormalities, and multiple organ failure. These disorders were largely attenuated by LR12. In particular, cardiovascular failure was dampened as attested by a better mean arterial pressure, cardiac index, cardiac power index, and S(v)O(2), despite lower norepinephrine requirements. LR12, a TREM-like transcript 1-derived peptide, exhibits salutary properties during septic shock in adult minipigs.

Topics: Animals; Blood Coagulation Disorders; Cardiovascular Agents; Cardiovascular Diseases; Hemodynamics; Hydroxyethyl Starch Derivatives; Hypotension; Male; Multiple Organ Failure; Random Allocation; Receptors, Immunologic; Shock, Septic; Swine; Swine, Miniature

Topics: Capillary Leak Syndrome; Cardiovascular Agents; Combined Modality Therapy; Diagnosis, Differential; Emergencies; Fatal Outcome; Female; Fluid Therapy; Humans; Hypotension, Orthostatic; Middle Aged; Monoclonal Gammopathy of Undetermined Significance; Multiple Myeloma; Pasteurella Infections; Pasteurella multocida; POEMS Syndrome; Respiration, Artificial; Shock, Septic; Skin Diseases, Bacterial; Ventricular Dysfunction, Left

The Surviving Sepsis Campaign (SSC) recommends Early Goal Directed Therapy (EGDT) in the treatment of septic shock, which requires key critical care skills and knowledge. This study evaluates the availability of these skills in Specialist Registrars in acute hospital specialities in the UK. A questionnaire was sent to Specialist Registrars in Anaesthetics, General Surgery and General Medicine throughout Scotland. One hundred and eighty five responses were obtained. One hundred percent of anaesthetists, 70% of surgeons and 51% of physicians were aware of EGDT Only 62 trainees (6% of surgeons, 79% of anaesthetists, 19% of physicians) had the full complement of skills and knowledge to implement EGDT. This study demonstrates that non-anaesthetic registrars in the UK lack both knowledge and skills required to provide EGDT. The main deficit was in awareness, demonstrating that knowledge of EGDT is not penetrating into specialities beyond anaesthesia. It is now time for the SSC to specifically target non-anaesthetic specialities.

Topics: Anesthesiology; Cardiovascular Agents; Catheterization; Clinical Competence; Critical Care; Family Practice; General Surgery; Health Care Surveys; Humans; Medical Staff, Hospital; Needs Assessment; Scotland; Shock, Septic

Topics: Anti-Bacterial Agents; Cardiovascular Agents; Clinical Protocols; Critical Care; Drug Therapy, Combination; Evidence-Based Medicine; Guideline Adherence; Humans; International Cooperation; Practice Guidelines as Topic; Sepsis; Shock, Septic

Sepsis is the most important reason for death among intensive care patients. This review will cover the actual definition of septic shock, and the difficulties regarding the diagnosis of sepsis. The principles of management of sepsis, the recently established principles as early goal directed therapy, low dose steroid substitution, insulin therapy, and the activated protein C are discussed.

Topics: Adrenal Cortex Hormones; Cardiovascular Agents; Clinical Trials as Topic; Combined Modality Therapy; Critical Care; Dose-Response Relationship, Drug; Drug Therapy, Combination; Hemodynamics; Hospital Mortality; Humans; Insulin; Oxygen Inhalation Therapy; Protein C; Recombinant Proteins; Shock, Septic; Survival Rate

Topics: Cardiovascular Agents; Fluid Therapy; Humans; Sepsis; Shock, Septic

To study the role of ghrelin in the late stage of septic shock in rats.. The rat model of septic shock was made by caecal ligation and perforation. At the time of operation ghrelin 10 nmol/kg was infused through femoral vein followed by a sc injection at 8 h after operation. Hemodynamic parameters including heart rate (HR), mean arterial blood pressure (MABP), LVdp/dtmax, and left ventricular end-diastolic pressure (LVEDP) in survival rats were measured at 18 h after surgery. Plasma glucose and lactate concentrations, plasma ghrelin level and myocardial ATP content were assayed. The mortality rate in rats with septic shock was also observed.. Compared to that of septic shock group, MABP of rats in ghrelin-treated group increased by 33 % (P <0.01). The values of +LVdp/dtmax and -LVdp/dtmax increased by 27 % and 33 %, respectively (P <0.01), but LVEDP decreased by 33 % (P < 0.01). The plasma glucose concentration and myocardial ATP content increased by 53 % and 22 %, respectively, but plasma lactate concentration decreased by 40 % in ghrelin-treated rats (P < 0.01). The plasma ghrelin level in rats with septic shock was 51 % higher than that of rats in sham group, and was negatively correlated with MABP and blood glucose concentration (r=-0.721 and -0.811, respectively, P <0.01). The mortality rates were 47 % (9/19) in rats with septic shock and 25 % (3/12) in rats of ghrelin-treated group, respectively.. Treatment with ghrelin could correct partly the abnormalities of hemodynamics and metabolic disturbance in septic shock of rats.

Topics: Adenosine Triphosphate; Animals; Blood Glucose; Cardiovascular Agents; Ghrelin; Hemodynamics; Lactic Acid; Male; Myocardium; Peptide Hormones; Random Allocation; Rats; Rats, Sprague-Dawley; Shock, Septic; Survival Rate

Mortality from septic shock in children has decreased by 92 percent in the last 36 years. The contributions of goal-directed therapy, intensive care, and other forms of support are responsible for this decrease. A deeper and more specific understanding of innate immunity and the biomolecular processes that operate in septic shock has offered the scientific basis to implement goal-directed therapies. However, therapies that are aimed specifically at manipulating the inflammatory cascade have yet to prove safe and effective.

Topics: Anti-Infective Agents; Cardiovascular Agents; Child; Humans; Incidence; Shock, Septic

Laparoscopy is increasingly used in severely ill and acutely septic patients. In animals undergoing laparoscopy, the hemodynamic response to sepsis is blunted. Specific interventions to augment the hemodynamic potential may make laparoscopic intervention a safer alternative in septic patients. We compared different interventions to improve hemodynamic performance during exploratory laparoscopy in a porcine endotoxic shock model.. Domestic pigs (n = 12) received intravenous lipopolysaccharide injection and underwent surgical abdominal exploration using either laparoscopy or conventional laparotomy. For comparison, pigs exposed to endotoxin underwent laparoscopy with these interventions: intravenous infusions of prostacyclin (n = 5) or indomethacin (n = 4), intravenous crystalloid resuscitation (n = 5), pulmonary hyperventilation (n = 4), or abdominal insufflation with air (n = 5). Hemodynamic measurements and blood gas analyses were obtained using Swan-Ganz and arterial catheters.. Septic animals treated with prostacyclin undergoing laparoscopy had a higher cardiac index (CI, p < 0.01), stroke volume (SV; p < 0.001) and oxygen delivery (p < 0.05) than the untreated group. Likewise, treatment with indomethacin was associated with a higher CI (p < 0.001), SV (p < 0.005), and oxygen delivery (p < 0.005) compared with the untreated group. These effects may be secondary to a decreased pulmonary vascular resistance, demonstrated in the animals that received either prostacyclin (p < 0.05) or indomethacin (p < 0.05). In addition, animals given aggressive fluid resuscitation had a significantly higher CI (p < 0.05) and SV (p < 0.001) than those with normal fluid resuscitation during laparoscopy. Manipulation of arterial pH by insufflation of the abdomen with air to create the pneumoperitoneum, or by aggressively hyperventilating the animals, did not improve CI.. Adverse effects of laparoscopy on cardiovascular hemodynamics in the septic state may be mediated by increased pulmonary vascular resistance, diminished venous return, or both. Specific interventions to reverse these variables may ameliorate hemodynamic changes seen.

Topics: Analysis of Variance; Animals; Antihypertensive Agents; Cardiovascular Agents; Disease Models, Animal; Endotoxemia; Epoprostenol; Escherichia coli; Fluid Therapy; Hemodynamics; Hydrogen-Ion Concentration; Indomethacin; Laparoscopy; Pneumoperitoneum, Artificial; Polysaccharides, Bacterial; Shock, Septic; Swine

Deaths in septic shock continue to occur at a high frequency despite current treatment programs. However, the mortality can be substantially decreased with a close bedside attendance of patients at risk and if the patient is transferred to an intensive care unit for intensive treatment and monitoring as soon as shock is suspected or established. The treatment program consists of adequate antibiotic administration in combination with massive doses of steroids and aggressive infusion therapy supplemented with cardiovascular drugs according to the hemodynamic response to the initial treatment.

Topics: Anti-Bacterial Agents; Cardiovascular Agents; Combined Modality Therapy; Critical Care; Drug Therapy, Combination; Hemodynamics; Humans; Shock, Septic; Steroids

Authors present their adopted measures, in the different clinical stages of endotoxic shock with a phisiological approach, paying special attention to those secondary to meningococcal infections.

Topics: Adrenal Cortex Hormones; Anti-Bacterial Agents; Cardiovascular Agents; Combined Modality Therapy; Fluid Therapy; Humans; Intensive Care Units; Meningococcal Infections; Shock, Septic; Vitamin K

Topics: Adrenal Cortex Hormones; Anti-Bacterial Agents; Cardiovascular Agents; Gram-Negative Aerobic Bacteria; Gram-Negative Anaerobic Bacteria; Humans; Infusions, Parenteral; Sepsis; Shock, Septic