Septic shock, as the most severe form of sepsis, is characterized by high mortality reaching 40% despite the use of the most modern standards of diagnosis and treatment. In the thanatogenesis of septic shock, vasoplegia plays a leading role, respectively, and therapy of the condition under discussion involves the use of vasoconstrictors, along with the standard prescription of infusion therapy, antibiotics and symptomatic treatment. The choice of a specific vasoactive drug is a difficult task for a practicing anesthetist, as along with undoubtedly positive properties, vasoconstrictors each have their own spectrum of undesirable side effects, which, of course, must be taken into account when determining treatment tactics.The aim of review: A comprehensive assessment of the multifactorial effect of various vasoconstrictors on the patient to determine the criteria for choosing the optimal drug (or a combination of drugs) in septic shock.The search was carried out using PubMed and Scopus databases, the final selection of 89 articles was carried out in accordance with the following criteria: relevance to the topic of this review and the nature of the article — only randomized controlled trials, guidelines and analytical reviews were included in the final analysis.External and internal mechanisms of vascular tone regulation are considered, including factors produced by endothelium (nitric oxide, prostacyclin, endothelin); vasoactive metabolites and autocoids — signal molecules of local action (serotonin, prostaglandins, thromboxane A2). Accordingly, drugs were analyzed the mechanism of action of which is related to the effect on adrenergic (adrenaline, dopamine, norepinephrine, phenylephrine, dobutamine), vasopressin (vasopressin, terlipressin, selepressin) receptors, synthetic analogues of angiotensin (angiotensin II) and drugs the non-vasopressor effect of which is not linked with the receptor apparatus (methylene blue, levosimendan, hydrocortisone).Conclusion. The high effectiveness of norepinephrine, its positive hemodynamic effects make the drug under discussion, in many ways, a universal remedy for the relief of septic shock. However, refractory shock may require the introduction of such high doses of norepinephrine that the occurrence of adverse reactions will become practically inevitable. The combined use of adrenergic and ligand V receptors, terlipressin, is intended to prevent these complications. However, to date, there are no clear recommendations on the use of terlipressin in septic shock, which limits its use in clinical practice.
<p><strong>Aim.</strong> To assess whether plasma mitochondrial DNA (mtDNA) levels in the early postoperative period can predict the development of systemic inflammatory response syndrome (SIRS) and multiple organ failure in patients undergoing cardiac surgery.</p><p><strong>Methods.</strong> This pilot, prospective, observational, cohort study included 85 patients undergoing cardiac surgery. Plasma mtDNA levels were determined immediately after the surgery, and the development of SIRS, acute kidney injury, acute heart failure, and adult respiratory distress syndrome was assessed.</p><p><strong>Results.</strong> The mtDNA levels showed good potential for predicting the development of SIRS within 1-2 days after the surgery (area under the curve = 0.74). Regarding the cut-off point, a mtDNA level of >0.54 ng/mL predicted the development of SIRS in the early postoperative period with a sensitivity of 73.7% and a specificity of 66%. The odds ratio for the development of acute kidney injury with/without SIRS was 3.4 [confidence interval (CI) = 1.27–9.08; p = 0.0149]; acute heart failure, 5.7 (CI = 2.20–14.84; p = 0.0003); and adult respiratory distress syndrome, 3.6 (CI = 1.01–11.10; p = 0.047).</p><p><strong>Conclusion</strong>. The plasma mtDNA levels in the early postoperative period can be used as a predictive marker for the development of SIRS and multiple organ failure in patients undergoing cardiac surgery. Moreover, SIRS is associated with the development of acute kidney injury, acute heart failure, and adult respiratory distress syndrome.</p><p><strong>Funding:</strong> The study did not have sponsorship.</p><p><strong>Conflict of interest:</strong> Authors declare no conflict of interest.</p><p>Received 25 March 2019. Revised 3 April 2019. Accepted 8 April 2019.</p><div> </div>
Background: Neutrophil activation is a mandatory stage and a sensitive marker of systemic inflammatory response. The development of this condition is associated with subsequent multiple organ failure which is the main indication for the patients stay in the intensive care unit. The search for drugs that could prevent the development of systemic inflammatory response and reduce mortality remains an urgent task of anesthesiology/resuscitation.Aim: To study the anti-inflammatory effect of dalargin, a synthetic analogue of lei-enkephalin, on human neutrophils in vitro.Materials and methods: The study was performed on blood neutrophils isolated from 5 healthy donors. A proportion of neutrophils were activated by 10 mkM formil-Met-Leu-Pro (fMLP) and 100 ng/mL lipopolysaccharide (LPS) with subsequent assessment of their activity by fluorescent antibodies to the degranulation markers CD11b and CD66b. Thereafter intact and activated neutrophils were treated with dalargin solution at concentrations of 50 and 100 mcg/mL.Results: Dalargin at 100 mcg/mL reduced the expression of CD11b molecules on the surface of intact neutrophils by 5.5-fold (p=0.008). On the contrary, LPS at a dose of 100 ng/mL increased the expression of the same molecules by 46% (p=0.08). The addition of dalargin at 50 mcg/mL to LPS-activated neutrophils reduced the expression of CD11b molecules (p=0.016). The addition of dalargin at 50 mcg/mL to fMLP-activated neutrophils significantly (p=0.008) reduced the expression of CD11b molecules and reversed their expression virtually to the level of the control. The addition of dalargin at 100 mcg/mL to neutrophils activated by fMLP at 10 mkM reduced the expression of CD11b on their surface to a level below the control by 23% (p=0.08).Conclusion: Dalargin at the studied concentrations has an anti-inflammatory effect on both intact and pre-activated bacterial components of neutrophils, thus inhibiting the process of activation and degranulation in a dose-dependent manner.
The purpose of the study was to compare the possibility of rapid activation of elderly patients after carotid endarterectomy performed under sevoflurane- or desflurane-based anesthesia. Materials and methods. 67 patients aged 75 to 89 years divided into two groups were examined. To maintain anesthesia, desflurane was used in the 1st group and sevoflurane was employed in the 2nd group. Results. Patients from the group receiving desflurane, experienced decreased ability to take a sip of water and to hold oneself in a sitting position, and were characterized by decreased time before the tracheal extubation. Conclusion. Desflurane-based anesthesia provided faster awakening and activation of elderly patients after carotid endarterectomy than the anesthesia with sevoflurane, which allowed to implement the fast-track recovery protocol. In addition, the desflurane-based anesthesia provided excellent manageability and less negative impact on the hemodynamics (within the drug concentration range of up to 1.3 MAC).
Purpose — to assess the efficacy of supplementation therapy for antithrombin deficiency in the combined treatment of sepsis.Materials and methods. A prospective-retrospective study of the efficacy of supplementation therapy for antithrombin deficiency during sepsis was carried out; 90 patients were examined. The patients were split into two groups whether antithrombin deficiency correction was or was not undertaken. The composite outcome — the incidence of cardiovascular complications as of day 28 from the therapy commencement — was chosen as the primary endpoint of the study. The secondary endpoints of the study were prevalence of adverse events as of day 28 from the therapy commencement and 180-day mortality.Results. There was no difference between the groups either in respect of 28-day mortality or composite outcome. Analysis of secondary endpoints revealed that in the group of patients who received antithrombin supplementation therapy, the risk of development of an acute renal injury was significantly lower on day 28 and 180 from therapy commencement: OR 3.5 [95% CI 1.05–11.66] at P=0.04 and OR 2.92 [95% CI 1.02–8.31] at P=0.045, respectively.Conclusion. Correction of antithrombin level to activity level ‘over 61%’ is associated with decreased incidence degree III acute kidney failure (KDIGO).
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