Catecholamines for inflammatory shock: a Jekyll-and-Hyde conundrum

Andreis, Davide T.; Singer, Mervyn

doi:10.1007/s00134-016-4249-z

Cited by 142 publications

(119 citation statements)

References 114 publications

(104 reference statements)

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“…Prolonged immobilization and organ support therapies can also alter the metabolism, not to mention the effect of repeated stress due to secondary infections and organs failure [17, 19, 20]. Our data thus suggest that a similar variability and complicated metabolic pathways exists also during the acute phase of critical illness [21]. …”

Section: Discussionmentioning

confidence: 83%

Can calculation of energy expenditure based on CO2 measurements replace indirect calorimetry?

et al. 2017

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BackgroundMethods to calculate energy expenditure (EE) based on CO2 measurements (EEVCO2) have been proposed as a surrogate to indirect calorimetry. This study aimed at evaluating whether EEVCO2 could be considered as an alternative to EE measured by indirect calorimetry.MethodsIndirect calorimetry measurements conducted for clinical purposes on 278 mechanically ventilated ICU patients were retrospectively analyzed. EEVCO2 was calculated by a converted Weir’s equation using CO2 consumption (VCO2) measured by indirect calorimetry and assumed respiratory quotients (RQ): 0.85 (EEVCO2_0.85) and food quotient (FQ; EEVCO2_FQ). Mean calculated EEVCO2 and measured EE were compared by paired t test. Accuracy of EEVCO2 was evaluated according to the clinically relevant standard of 5% accuracy rate to the measured EE, and the more general standard of 10% accuracy rate. The effects of the timing of measurement (before or after the 7th ICU day) and energy provision rates (<90 or ≥90% of EE) on 5% accuracy rates were also analyzed (chi-square tests).ResultsMean biases for EEVCO2_0.85 and EEVCO2_FQ were -21 and -48 kcal/d (p = 0.04 and 0.00, respectively), and 10% accuracy rates were 77.7 and 77.3%, respectively. However, 5% accuracy rates were 46.0 and 46.4%, respectively. Accuracy rates were not affected by the timing of the measurement, or the energy provision rates at the time of measurements.ConclusionsCalculated EE based on CO2 measurement was not sufficiently accurate to consider the results as an alternative to measured EE by indirect calorimetry. Therefore, EE measured by indirect calorimetry remains as the gold standard to guide nutrition therapy.

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Section: Discussionmentioning

confidence: 83%

Can calculation of energy expenditure based on CO2 measurements replace indirect calorimetry?

et al. 2017

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“…Critical illness and management in a critical care unit are characterised by a severe and abnormally prolonged stressor response; this response may become maladaptive. (21) Given this premise, attenuation of an excessive adrenergic component of the stress reaction is a tempting therapeutic option during sepsis and other critically ill states.…”

Section: β-Antagonists and Decatecho-laminization In Critically Ill Pmentioning

confidence: 99%

Do we need an individual approach to atrial fibrillation and adrenergic overload in the critically ill?

2017

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Despite catecholamines being lifesaving drugs, they can also be harmful. Adrenergic overload is one of the major causes of supra-and ventricular arrhythmias, which induce haemodynamic instability of critically ill patients. In this paper we will focus on the pathophysiology of atrial fibrillation (AF), the importance of adrenergic overload for triggering AF, the importance of the autonomic nervous system and we will challenge the importance of decreasing adrenergic load with selective and nonselective β-blockers, which have different effects on the metabolism of the severely ill. We will also emphasize the importance of an individual approach due to pharmacogenetic differences in β-adrenergic signalling.

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“…It should be potent, but with a non-adrenergic mechanism of action to contribute to the de-catecholamination of intensive care therapy (2). To date, catecholamines still are the first line vasopressors for vasodilatory shock.…”

mentioning

confidence: 99%

“…To date, catecholamines still are the first line vasopressors for vasodilatory shock. But it is also known that especially high doses are associated with several deleterious side effects (2,3) and are independently associated with increased mortality rates (3)(4)(5). For example, patients receiving more than 0.2 µg/kg/min norepinephrine or equivalent have a mortality risk of >50% (6).…”

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confidence: 99%

ATHOS-3 and the knights of the round table—the search for the holy grail of vasopressors

et al. 2017

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The international, multicentre, double-blinded, randomized, controlled ATHOS-3 trial by Khanna and colleagues (1) w a s c o n d u c t e d f r o m M a y 2 0 1 5 t o J a n u a r y 2 0 1 7 in nine countries across Europe, North America, and Australia. ATHOS-3 was designed to answer two primary endpoints within a study period of 48 h.First, in the initial 3 h, a "vasopressor" trial was conducted to test the hypothesis, that mean arterial pressure (MAP) of patients who already receive more than 0.2 µg/kg/min norepinephrine or the equivalent dose of another conventional vasopressor in vasodilatory shock states can be raised by angiotensin II. Therefore, angiotensin II was titrated to increase MAP to at least 75 mmHg (starting at 20 ng/kg/min to max 200 ng/kg/min) in the intervention group while standard of care vasopressors were held constant. The primary endpoint was defined as vasopressor response due to the infusion of angiotensin II or placebo (MAP ≥75 mmHg, or an increase in MAP from baseline ≥10 mmHg). Second, in the period between 3 and 48 h, a clinically more relevant study design was used to test the ability of angiotensin II in maintaining MAP levels between 65-75 mmHg and reducing catecholamine doses. Therefore, an infusion of angiotensin II equivalent to 1.25 to 40 ng/kg/min was compared to placebo; both in combination with the respective standard of care vasopressors. The study protocol included a non-binding adjustment scheme for vasopressors: briefly, the attending physician could choose between standard of care vasopressors and angiotensin II (in doses between 1.25 and 40 ng/kg/min) to maintain a MAP between 65-75 mmHg.Overall, 321 patients were included in the analysis: 163 received angiotensin II, and 158 received placebo. There were no statistically significant differences between groups in baseline characteristics and demographics. Patients in both treatment groups were severely ill, as suggested by high vasopressor doses [median (interquartile range): angiotensin II group 0.33 µg/kg/min (0.23-0.56), and placebo group 0.34 µg/kg/min (0.23-0.56)] and high disease severity scores {e.g., APACHE II Score, ranging from 0-71 with higher scores indicating greater disease severity, was 28 [22][23][24][25][26][27][28][29][30][31][32][33] in all patients}.At the end of the initial 3-h period significantly more patients met the criteria for a positive vasopressor response in the angiotensin II group compared to the placebo group (70% vs. 23%, P<0.001) corresponding to a significantly greater increase in MAP in the angiotensin II group (12.5 vs. 2.9 mmHg, P<0.001). Regarding the second major endpoint, mean dosages of the standard of care vasopressors were consistently lower in the angiotensin II group compared to the placebo group. In addition, at the end of the 48-h interventional period, the improvement of the cardiovascular sequential organ failure assessment score (SOFA) was more pronounced in the angiotensin II group Editorial ATHOS-3 and the knights of the round table-the search for the holy grail of vas...

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Catecholamines for inflammatory shock: a Jekyll-and-Hyde conundrum

Cited by 142 publications

References 114 publications

Can calculation of energy expenditure based on CO2 measurements replace indirect calorimetry?

Can calculation of energy expenditure based on CO2 measurements replace indirect calorimetry?

Do we need an individual approach to atrial fibrillation and adrenergic overload in the critically ill?

ATHOS-3 and the knights of the round table—the search for the holy grail of vasopressors

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