Vasopressors for hypotensive shock

Havel, Christof; Arrich, Jasmin; Losert, Heidrun; Gamper, Gunnar; Müllner, Marcus; Herkner, Harald

doi:10.1002/14651858.cd003709.pub3

Cited by 67 publications

(56 citation statements)

References 55 publications

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“…The initial therapy for hypotension is fluid replacement followed by vasopressor or inotropic support, which depends on the type and severity of shock. However, despite recently published guidelines, large prospective comparisons, and meta-analyses, [1][2][3][4][5][6][7][8][9][10][11] the first-choice vasopressor is still controversial. At our institution, VU University Medical Centre, Amsterdam, the Netherlands, and at other facilities, norepinephrine is the vasopressor used first, regardless of the type and origin of shock, because equivalently effective doses of dopamine may be associated with more adverse effects and less beneficial outcomes.…”

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confidence: 99%

High-Dose Norepinephrine Treatment: Determinants of Mortality and Futility in Critically Ill Patients

Döpp-Zemel

Groeneveld

2013

American Journal of Critical Care

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Background Critically ill patients with circulatory shock sometimes need rescue treatment with high doses of norepinephrine, a treatment that may be associated with a poor outcome because of excessive vasoconstriction. Objective To evaluate the outcome of treatment and its determinants in patients with circulatory shock who received high doses of norepinephrine in the intensive care unit and to identify indicators of futility for the treatment. Methods A retrospective study was done on 113 consecutive patients with circulatory shock who received 0.9 µg/kg per minute or greater of norepinephrine during at least 1 hour at any time in the intensive care unit. Data were extracted from the electronic patient data management system according to a predefined checklist. Results A total of 39 patients survived for 28 days after admission to the intensive care unit. The variables independently associated with 28-day mortality in multivariable models included low urine flow, high lactate levels, high organ failure score, high prothrombin time, and need for epinephrine cotreatment. The reason, dose, and duration of norepinephrine administration did not have prognostic significance. Scores greater than 40 on the Acute Physiology and Chronic Health Evaluation II, bicarbonate levels less than 9.0 mEq/L, or receipt of an epinephrine dose of 0.25 µg/kg per minute or greater were associated with 100% mortality. Conclusions Although the cause of shock and treatment with norepinephrine were not predictive of death when high doses of the drug were deemed necessary, rescue treatment with high-dose norepinephrine is futile in patients with severe disease and metabolic acidemia. (American Journal of Critical Care. 2013;22:22-32) HIGH-DOSE 1,2,5,6,9,10,13,15-18 A maximum tolerable dose has not been determined, even though excessive dosing is associated with a risk for extreme vasoconstriction, tissue hypoperfusion, and increased mortality. Consequently, many intensivists do not use doses greater than 100 µg/min or 1.2 µg/kg per minute. 2,5,8,[17][18][19][20][21][22][23] Indeed, use of high doses may be futile (ie, associated with 100% mortality), as reported previously, [17][18][19]21 but currently the indicators for futility of this rescue treatment are unknown. They may vary according to underlying disease, causes of shock, and other factors. Abid et al 19 found that a score greater than 12 on the Sequential Organ Failure Assessment (SOFA) was associated with 100% mortality during (delayed) norepinephrine treatment for shock. Lactate levels may be confounded by the β-adrenergic effects of catecholamines, thereby potentially making the well-known prognostic value of the drugs in shock less helpful during treatment with norepinephrine, which has both α-and β-adrenergic properties. 1,3,5,10,13,23,24 The purpose of our study was to evaluate the outcome of ICU patients who received doses of norepinephrine of 0.9 µg/kg per minute or greater C ritically ill patients in the intensive care unit (ICU) may die of circulatory shock or its se...

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confidence: 99%

High-Dose Norepinephrine Treatment: Determinants of Mortality and Futility in Critically Ill Patients

Döpp-Zemel

Groeneveld

2013

American Journal of Critical Care

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“…Moreover, vasopressors may induce a ventriculoarterial mismatch if myocardial performance does not match the effects on vasopressor tone. 9 Norepinephrine, epinephrine, and phenylephrine are commonly used as vasopressor agents during septic shock. 6 Current evidence based on level A studies does not support recommendation of one vasopressor over another; indeed, norepinephrine, phenylephrine, and epinephrine can be used safely with similar survival outcomes.…”

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confidence: 99%

“…6 Current evidence based on level A studies does not support recommendation of one vasopressor over another; indeed, norepinephrine, phenylephrine, and epinephrine can be used safely with similar survival outcomes. 9,10 When considering nonseptic cardiogenic shock or myocardial failure after cardiac surgery, both epinephrine 11 and norepinephrine 12 are recommended. In general, for an equal increase in arterial pressure, cardiac output and oxygen delivery appear to be increased most with epinephrine, intermediately with norepinephrine, and less with phenylephrine.…”

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confidence: 99%

Comparison of Equipressor Doses of Norepinephrine, Epinephrine, and Phenylephrine on Septic Myocardial Dysfunction

et al. 2012

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Background: Myocardial depression is a frequent event during septic shock and may mimic a cardiogenic shock state with decreased cardiac output. Nevertheless, data are scarce regarding the myocardial effects of vasopressors used to treat hypotension. In this study, the authors compared the effects of three commonly used vasopressors acting on different adrenergic receptors on myocardial function in a rodent model of septic shock, as explored with conductance catheter and positron emission tomography. Methods: Septic shock was induced in rats by peritonitis. Eighteen hours after septic insult, vasopressors were titrated to increase mean arterial pressure by 20% compared with baseline values. Results: We observed that peritonitis was associated with arterial hypotension and systolodiastolic dysfunction. Norepinephrine and epinephrine improved mean arterial pressure, cardiac output, and preload recruitable stroke work, a load-independent measure of systolic function, as well as diastolic function and ventriculoarterial coupling. Heart rate, myocardial oxygen consumption, and arrhythmia incidence were furthermore increased in the epinephrine group. Conversely, phenylephrine, a peripheral ␣-agonist, exhibited

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“…That means nine patients need to be treated to prevent one additional death (19). However, the Havel's review failed to identify beneficial effect of norepinephrine on mortality reduction over dopamine (20). Together with the marginal significant level in the Zhou's study, we conclude that the mortality reduction effect is still controversial that requires further investigations.…”

Section: Dopamine and Norepinephrinementioning

confidence: 83%

Vasoactive agents for the treatment of sepsis

Zhang

Chen

2016

Ann. Transl. Med.

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The article describes some commonly used vasoactive agents in patients with septic shock. Depending on their distinct pharmacological properties, their effects on vascular bed and cardiac function are different. For example, dopamine has equivalent effect on heart and vasculature, which can result in increases in cardiac output, mean arterial pressure and heart rate. Dobutamine is considered as inodilator because it has potent effect on cardiac systole and vasculature. Patients with sepsis and septic shock sometimes have coexisting cardiac dysfunction that justifies the use of dobutamine. Levosimendan is a relatively new agent exerting its inodilator effect by increasing sensitivity of myocardium to calcium. Some preliminary studies showed a promising result of levosimendan on reducing mortality.

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Vasopressors for hypotensive shock

Cited by 67 publications

References 55 publications

High-Dose Norepinephrine Treatment: Determinants of Mortality and Futility in Critically Ill Patients

High-Dose Norepinephrine Treatment: Determinants of Mortality and Futility in Critically Ill Patients

Comparison of Equipressor Doses of Norepinephrine, Epinephrine, and Phenylephrine on Septic Myocardial Dysfunction

Vasoactive agents for the treatment of sepsis

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