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![Figure 1: Vasopressor classification [8,91] a: Adrenergic agents mimic...](publication/282426459/figure/fig1/AS:567372503318528@1512283554720/Vasopressor-classification-8-91-a-Adrenergic-agents-mimic-sympathetic-nervous-system_Q320.jpg)
Despite the growing body of evidence evaluating the efficacy of vasoactive agents in the management of hemodynamic instability and circulatory shock, it appears no agent is superior. This is becoming increasingly accepted as current guidelines are moving away from detailed algorithms for the management of shock, and instead succinctly state that va...
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Context 1
... optimizing SV and HR will improve CO, MAP, and DO 2 , keeping in mind that SV and overall myocardial performance is determined by five other factors in addition to inotropy (contractility) that requires consideration: (1) HR and rhythm (atrioventricular synchrony), (2) myocardial blood flow, (3) preload, (4) afterload, and (5) diastolic function. However, depending on the underlying cause of shock, the sympathetic nervous system compensation intended to restore normal organ perfusion pressure is manifested in different ways [ Table 1]. [15,16] In the example of distributive shock, the underlying pathophysiology prevents the compensatory increase in SVR seen in most types of circulatory shock, resulting in refractory hypotension despite a normal or elevated CO and DO 2 . ...
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Citations
... Vasoactive drugs are inotropic, vasopressor, or vasodilator agents that provide temporary hemodynamic support to assist in the recovery of hemodynamically unstable patients [18]. Critically ill patients are already at risk of a broad spectrum of deleterious effects of immobilization [19]. ...
Background
Vasoactive drugs are one of the most common patient-related barriers to early mobilization. Little is known about the hemodynamic effects of early mobilization on patients receiving vasoactive drugs. This study aims to observe and describe the impact of mobilization on the vital signs of critical patients receiving vasoactive drugs as well as the occurrence of adverse events.
Methods
This is a cohort study performed in an Intensive Care Unit with patients receiving vasoactive drugs. All patients, either mobilized or non-mobilized, had their clinical data such as vital signs [heart rate, respiratory rate, systolic blood pressure, diastolic blood pressure, mean arterial pressure, and oxygen saturation], type and dosage of the vasoactive drug, and respiratory support collected at rest. For mobilized patients, the vital signs were also collected after mobilization, and so was the highest level of mobility achieved and the occurrence of adverse events. The criteria involved in the decision of mobilizing the patients were registered.
Results
53 patients were included in this study and 222 physiotherapy sessions were monitored. In most of the sessions (n = 150, 67.6%), patients were mobilized despite the use of vasoactive drugs. There was a statistically significant increase in heart rate and respiratory rate after mobilization when compared to rest (p<0.05). Only two (1.3%) out of 150 mobilizations presented an adverse event. Most of the time, non-mobilizations were justified by the existence of a clinical contraindication (n = 61, 84.7%).
Conclusions
The alterations observed in the vital signs of mobilized patients may have reflected physiological adjustments of patients’ cardiovascular and respiratory systems to the increase in physical demand imposed by the early mobilization. The adverse events were rare, not serious, and reversed through actions such as a minimal increase of the vasoactive drug dosage.
... Subsequent failure to act early on patient deterioration and hemodynamic instability can result in care delays, adverse events, unanticipated transfers to higher levels of care, increased lengths of stay, and unexpected deaths (3). The current standard for identifying such instability is based mainly on abnormal vital signs, with several contemporary medical reviews using measures of hypotension (systolic arterial pressure < 90 mm Hg or mean arterial pressure [MAP] < 70 mm Hg) and tachycardia (> 100 beats/min) (4)(5)(6)(7)(8). However, monitoring of such vital signs has limitations, including intermittent and irregular monitoring frequency, limited accuracy (specifically of noninvasive blood pressure monitoring), and accidental errors when validating vitals and entering data into the electronic medical record (9). ...
OBJECTIVES:. Delayed identification of hemodynamic deterioration remains a persistent issue for in-hospital patient care. Clinicians continue to rely on vital signs associated with tachycardia and hypotension to identify hemodynamically unstable patients. A novel, noninvasive technology, the Analytic for Hemodynamic Instability (AHI), uses only the continuous electrocardiogram (ECG) signal from a typical hospital multiparameter telemetry monitor to monitor hemodynamics. The intent of this study was to determine if AHI is able to predict hemodynamic instability without the need for continuous direct measurement of blood pressure.
DESIGN:. Retrospective cohort study.
SETTING:. Single quaternary care academic health system in Michigan.
PATIENTS:. Hospitalized adult patients between November 2019 and February 2020 undergoing continuous ECG and intra-arterial blood pressure monitoring in an intensive care setting.
INTERVENTIONS:. None.
MEASUREMENTS AND MAIN RESULTS:. One million two hundred fifty-two thousand seven hundred forty-two 5-minute windows of the analytic output were analyzed from 597 consecutive adult patients. AHI outputs were compared with vital sign indications of hemodynamic instability (heart rate > 100 beats/min, systolic blood pressure < 90 mm Hg, and shock index of > 1) in the same window. The observed sensitivity and specificity of AHI were 96.9% and 79.0%, respectively, with an area under the curve (AUC) of 0.90 for heart rate and systolic blood pressure. For the shock index analysis, AHI’s sensitivity was 72.0% and specificity was 80.3% with an AUC of 0.81.
CONCLUSIONS:. The AHI-derived hemodynamic status appropriately detected the various gold standard indications of hemodynamic instability (hypotension, tachycardia and hypotension, and shock index > 1). AHI may provide continuous dynamic hemodynamic monitoring capabilities in patients who traditionally have intermittent static vital sign measurements.
... Due to their vasoconstrictive properties, they are often used in critical care for cardiopulmonary resuscitation, postoperative heart surgery care, and the management of hypotension associated with the different types of shock, in order to improve the hemodynamic function and restore tissue perfusion, and hence improving tissue oxygen delivery (1,10,11). The main drugs with vasopressor activity used in the ICU may be classified into two groups: the non-adrenergic agents (vasopressin) and the adrenergic agents (adrenaline, norepinephrine, dopamine, ephedrine, etilefrine and phenylephrine) (12,13). ...
Introduction
Vasopressors are essential in the management of various types of shock.
Objective
To establish the trend of vasopressors use in the intensive care units (ICU) in a population of patients affiliated with the Colombian Health System, 2010-2017.
Methods
Observational trial using a population database of patients hospitalized in eleven ICUs in various cities in Colombia. The drugs dispensed to hospitalized patients over 18 years old, from January 2010 until December 2017 were considered. A review and analysis of the vasopressors dispensed per month was conducted, taking into account sociodemographic and pharmacological variables (vasopressor used and daily doses defined per 100/beds/day (DBD).
Results
81,348 dispensations of vasopressors, equivalent to 26,414 treatments in 19,186 patients receiving care in 11 hospitals from 7 cities were reviewed. The mean age of patients was 66.3±18.1 years and 52.6 % were males. Of the total number of treatments recorded, 17,658 (66.8 %) were with just one vasopressor. Norepinephrine was the most frequently prescribed drug (75.9 % of the prescriptions dispensed; 60.5 DBD), followed by adrenaline (26.6 %; 41.6 DBD), dopamine (19.4%), dobutamine (16.0 %), vasopressin (8.5 %) and phenylephrine (0.9 %). The use of norepinephrine increased from 2010 to 2017 (+6.19 DBD), whilst the use of other drugs decreased, particularly the use of adrenaline (-60.6 DBD) and dopamine (-10.8 DBD).
Conclusions
Norepinephrine is the most widely used vasopressor showing a growing trend in terms of its use during the study period, which is supported by evidence in favor of its effectiveness and safety in patients with shock.
... In the past, many similar cases have been reported, and some have even led to life-threatening anaphylaxis. In addition to anaphylaxis, there are other causes of perioperative shock, including sudden reductions in total blood volume through acute blood losses, as in severe hemorrhage; sudden reductions in cardiac output, as in myocardial infarction (heart attack); and widespread dilation of the blood vessels, as in some forms of infection or allergic agent [3]. Herein, we present a patient that sustained anaphylaxis due to the insertion of chlorhexidine-impregnated CVC combined with cardiogenic shock simultaneously. ...
... The same medications (Fentanyl, Lidocaine, Propofol, Cisatracurium and Sevoflurane) were used for anesthesia induction and maintenance during the last surgery the patient had received; additionally, no other medication was given to the patient before hemodynamic collapse, so it is likely that the inserted antimicrobial CVC triggered the anaphylaxis reaction and induced hemodynamic instability, if the unstable vital signs are attributed to allergic reaction. Although anaphylactic shock can trigger unstable vital signs, so can cardiogenic shock [3]. During resuscitation, the TEE exam revealed poor cardiac wall motion. ...
... Since the introduction of preoperative α-blockade, both diagnostic and surgical techniques as well as anaesthesiology have evolved, with continuous invasive haemodynamic monitoring and effective short-acting drugs now being available for intraoperative BP control 14 . Given these advances, it is unclear whether preoperative α-blockade remains necessary. ...
... Shao et al. 24 Brunaud et al. 22 Groeben et al. 23 Heterogeneity: I 2 = 83%, τ 2 = 63·5, P < 0·01 Test for overall effect: Z = 0·04, P = 0·97 79 38 41 158 106 (14) 89 (13) 95 (15) 104 (14) 90 (15) ...
Background:
Preoperative α-blockade in phaeochromocytoma surgery is recommended by all guidelines to prevent intraoperative cardiocirculatory events. The aim of this meta-analysis was to assess the benefit of such preoperative treatment compared with no treatment before adrenalectomy for phaeochromocytoma.
Methods:
A systematic literature search was undertaken in MEDLINE, Web of Science and CENTRAL without language restrictions. Randomized and non-randomized comparative studies investigating preoperative α-blockade in phaeochromocytoma surgery were included. Data on perioperative safety, effectiveness and outcomes were extracted. Pooled results were calculated as an odds ratio or mean difference with 95 per cent confidence interval.
Results:
A total of four retrospective comparative studies were included investigating 603 patients undergoing phaeochromocytoma surgery. Mortality, cardiovascular complications, mean maximal intraoperative systolic and diastolic BP, and mean maximal intraoperative heart rate did not differ between patients with or without α-blockade. The certainty of the evidence was very low owing to the inferior quality of studies.
Conclusion:
This meta-analysis has shown a lack of evidence for preoperative α-blockade in surgery for phaeochromocytoma. RCTs are needed to evaluate whether preoperative α-blockade can be abandoned.
... Vasopressin, also known as "antidiuretic hormone, " is stored in the pituitary gland and released after hypotension or pain stimulus, and leads to vasoconstriction, consequently increasing SVR (29). It is not associated with the adverse effects of adrenergic agents, and enables an increase in MAP without adversely affecting CO (33). Another agent used to increase SVR is methylene blue. ...
... This reduces the responsiveness of vessels to vasodilators such as NO (34). Both vasopressin and methylene blue can be used to reverse vasoplegia, however methylene blue is recommended as a strategy of last resort (33). ...
... Common vasoactive drugs and their effects. Adapted with permission(32,33). ...
Cardiothoracic surgeries are complex procedures during which the patient cardiovascular physiology is constantly changing due to various factors. Physiological changes begin with the induction of anesthesia, whose effects remain active into the postoperative period. Depending on the surgery, patients may require the use of cardiopulmonary bypass and cardioplegia, both of which affect postoperative physiology such as cardiac index and vascular resistance. Complications may arise due to adverse reactions to the surgery, causing hemodynamic instability. In response, fluid resuscitation and/or vasoactive agents with varying effects may be used in the intraoperative or postoperative periods to improve patient hemodynamics. These factors have important implications for lumped-parameter computational models which aim to assist surgical planning and medical device evaluation. Patient-specific models are typically tuned based on patient clinical data which may be asynchronously acquired through invasive techniques such as catheterization, during which the patient may be under the effects of drugs such as anesthesia. Due to the limited clinical data available and the inability to foresee short-term physiological regulation, models often retain preoperative parameters for postoperative predictions; however, without accounting for the physiologic changes that may occur during surgical procedures, the accuracy of these predictive models remains limited. Understanding and incorporating the effects of these factors in cardiovascular models will improve the model fidelity and predictive capabilities.
... Vasoactive Drugs, their Effects on the Intestinal Vasculature and their Recommended Use(s) .48 ...
Nonocclusive mesenteric ischemia (NOMI) is a condition that can encompass ischemia, inflammation, and infarction of the intestinal wall. In contrast to most patients with acute mesenteric ischemia, NOMI is distinguished by patent arteries and veins. The clinical presentation of NOMI is often insidious and nonspecific, resulting in a delayed diagnosis. Patients most at risk are those with severe acute and critical disease, including major surgery and trauma. Nonocclusive mesenteric ischemia is part of a spectrum, from mild, asymptomatic, and an unexpected finding on CT scanning, through to those exhibiting abdominal distension and peritonitis. Severe NOMI is associated with a significant mortality rate. This review of NOMI pathophysiology was conducted to document current concepts and evidence, to examine the implications for diagnosis and treatment, and to identify gaps in knowledge that might direct future research. The key pathologic mechanisms involved in the genesis of NOMI represent an exaggerated normal physiological response to maintain perfusion of vital organs at the expense of mesenteric perfusion. A supply–demand mismatch develops in the intestine due to the development of persistent mesenteric vasoconstriction resulting in reduced blood flow and oxygen delivery to the intestine, particularly to the vulnerable superficial mucosa. This mismatch can be exacerbated by raised intra-abdominal pressure, enteral nutrition, and the use of certain vasoactive drugs, ultimately resulting in the development of intestinal ischemia. Strategies for prevention, early detection, and treatment are urgently needed.
... By providing a surrounding mimicking both the standardized process and dynamic crisis, high-fidelity simulation improves active memorization and enhances appropriate behaviors in real life while sparing patients from potential harm. [8] In addition, the hemodynamic data obtained from the flow simulation can be directly used to investigate the flow patterns as well as clinically important variables such as pressure gradients, wall shear stresses, and vortex propagation. [5] To conclude, the proliferation of three/four-dimensional imaging technologies, increasing computational speeds, improved simulation algorithms, and the widespread availability of powerful computing platforms is enabling simulations of cardiac hemodynamics with unprecedented speed and fidelity. ...
... In an excellent systematic review of pharmacologic agents for acute hemodynamic instability, Morozowich and Ramakrishna included MB as a "pure vasoconstrictor" and mentioned "an passant" that the MB use is justified as "rescue therapy." [1] Targeting MB for vasoplegic syndrome (VS) in a personal statement including questions, answers, doubts, and certainties, the following conclusions were drawn: [2,3] (1) The recommended doses are safe (the lethal dose is 40 mg/kg); (2) MB did not cause endothelial dysfunction; (3) the MB effect appears in cases of NO upregulation; (4) MB is not a vasoconstrictor; (5) it is possible that the MB acts through this "crosstalk" mechanism; (6) the most used dosage is 2 mg/kg as intravenous bolus followed by the same continuous infusion because the plasma concentrations strongly decay in the first 40 min; (7) there are no definitive multicentric studies, MB, at present, is the best, maybe it is the safest and cheapest option, but (8) there is a possible "window of opportunity" for the MB's effectiveness. [2,3] ...
