15 Apr 06
Posted in Critical Care, Inotropic support, Sepsis at 17:32 by Laci
By WO Schreuder, AJ Schneider, AB Groeneveld and LG Thijs
Chest, 1989;95:1282-1288
The effects of continuously infused dopamine and norepinephrine on hemodynamics, oxygen metabolism, and right ventricular (RV) performance were studied by crossover design in ten patients with septic shock who needed treatment with vasoactive drugs after fluid replacement. Standard hemodynamic measurements were obtained and RV performance assessed before and 1 h after the start of the infusion. All but one patient had pulmonary hypertension, and in seven the RV ejection fraction (RVEF) was lower than 50 percent at baseline. Drugs were titrated to a systolic arterial blood pressure of mean 106 +/- 18 mm Hg for dopamine and 116 +/- 20 mm Hg for norepinephrine (NS). Dopamine infusion increased the cardiac index (CI) 16 percent (p less than 0.02), but heart rate and systemic and pulmonary vascular resistances were unchanged. With norepinephrine CI was unchanged, a heart rate decreased 7 percent (p less than 0.05), and systemic and pulmonary vascular resistance increased 35 and 26 percent, respectively (p less than 0.05). With both drugs, RV volumes and RVEF remained unchanged, and systemic oxygen consumption increased equally (by 19 percent for dopamine and 22 percent for norepinephrine, p less than 0.05); systemic oxygen delivery rose by 17 percent during dopamine infusion and was unchanged during norepinephrine infusion. Norepinephrine increased oxygen extraction vs dopamine (p less than 0.05). There were no differences in urinary output. Norepinephrine may improve the RV oxygen supply/demand ratio, but this potentially beneficial effect on RV ejection fraction may be offset by a concomitant increase in pulmonary vascular resistance and RV afterload. Norepinephrine may not adversely affect the peripheral circulation. In short-term treatment of volume- resuscitated, severe septic shock complicated by pulmonary hypertension and impaired RV performance, norepinephrine may be at least as effective as dopamine.
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13 Apr 06
Posted in Critical Care, Statin at 18:57 by Laci
By RW Thomsen, HH Hundborg, SP Johnsen, L Pedersen, HT Sorensen, HC Schonheyder et al
Critical Care Medicine 2006;34(4):1080-1086
Objective
To examine the association between preadmission statin use and mortality among patients with bacteremia in a population-based setting.
Design
Observational study based on prospective registration of bacteremia episodes and mortality over a 6-yr period.
Setting
North Jutland County, Denmark (population, 500,000).
Patients
A total of 5,353 adult patients hospitalized with bacteremia from 1997 to 2002. Individuals treated with statins (n = 176) were identified by record-linkage with the County Prescription Database.
Measurements and Main Results
We compared mortality rates 0-30 and 31-180 days after bacteremia in patients with and without preadmission statin use, adjusted for gender, age group, level of comorbidity, alcohol-related conditions, use of immunosuppressive drugs and systemic antibiotics, and focus on infection. The 30-day mortality in statin users vs. nonusers was similar (20.0% vs. 21.6%, adjusted mortality rate ratio 0.93, 95% confidence interval 0.66-1.30). Among survivors after 30 days, however, statin therapy was associated with a substantially decreased mortality up until 180 days after the bacteremia (8.4% vs. 17.5%, adjusted mortality rate ratio 0.44, 95% confidence interval 0.24-0.80). This tendency toward similar short-term and decreased longer term mortality associated with statin use was observed consistently in both community-acquired and nosocomial bacteremia episodes and when analyses were restricted to patients with previous cardiovascular discharge diagnoses or diabetes.
Conclusions
This study provides evidence against the hypothesis that statin use has an effect on short-term mortality after bacteremia. Statin use was, however, associated with a substantially decreased mortality between 31 and 180 days after bacteremia.
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Posted in Critical Care, Sepsis at 18:54 by Laci
By NI Shapiro, MD Howell, D Talmor, D Lahey, L Ngo, et al
Critical Care Medicine 2006;34:1025-1032, April 2006.
Objectives
To describe the effectiveness of a comprehensive, interdisciplinary sepsis treatment protocol with regard to both implementation and outcomes and to compare the mortality rates and therapies of patients with septic shock with similar historical controls.
Design
Prospective, interventional cohort study with a historical control comparison group.
Setting
Urban, tertiary care, university hospital with 46,000 emergency department visits and 4,100 intensive care unit admissions annually.
Patients
Inclusion criteria were a) emergency department patients aged >=18 yrs, b) suspected infection, and c) lactate of >4 mmol/L or septic shock. Exclusion criteria were a) emergent operation, b) prehospital cardiac arrest, and c) comfort measures only. Time period: protocol, November 10, 2003, through November 9, 2004; historical controls, February 1, 2000, through January 31, 2001.
Intervention
A sepsis treatment pathway incorporating empirical antibiotics, early goal-directed therapy, drotrecogin alfa, steroids, intensive insulin therapy, and lung-protective ventilation.
Measurements and Main Results
There were 116 protocol patients, with a mortality rate of 18% (11-25%), of which 79 patients had septic shock. Comparing these patients with 51 historical controls, protocol patients received more fluid (4.0 vs. 2.5 L crystalloid, p < .001), earlier antibiotics (90 vs. 120 mins, p < .013), more appropriate empirical coverage (97% vs. 88%, p < .05), more vasopressors in the first 6 hrs (80% vs. 45%, p < .001), tighter glucose control (mean morning glucose, 123 vs. 140, p < .001), and more frequent assessment of adrenal function (82% vs. 10%, p < .001), with a nonstatistically significant increase in dobutamine use (14% vs. 4%, p = .06) and red blood cell transfusions (30% vs. 18%, p = .07) in the first 24 hrs. For protocol patients with septic shock, 28-day in-hospital mortality was 20.3% compared with 29.4% for historical controls (p = .3).
Conclusions
Clinical implementation of a comprehensive sepsis treatment protocol is feasible and is associated with changes in therapies such as time to antibiotics, intravenous fluid delivery, and vasopressor use in the first 6 hrs. No statistically significant decrease in mortality was demonstrated, as this trial was not sufficiently powered to assess mortality benefits.
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Posted in Critical Care, Early goal directed therapy, Glycemic control, rhAPC, Sepsis, Steroid at 18:38 by Laci
By A Kortgen, P Niederprum, M Bauer
Critical Care Medicine. 2006;34:943-949
Objective
To assess the impact of an algorithm defining resuscitation according to early goal-directed therapy, glycemic control, administration of stress doses of hydrocortisone, and use of recombinant human activated protein C (rhAPC) on measures of organ dysfunction and outcome in septic shock.
Design
Retrospective cohort study.
Setting
Multidisciplinary ten-bed intensive care unit of a university hospital.
Patients
Sixty patients were analyzed: 30 consecutive patients fulfilling criteria for diagnosis of septic shock, treated from September 2002 until December 2003 after implementation of a standard operating procedure (SOP) for severe sepsis and septic shock; and 30 patients with septic shock treated from January until August 2002 in the same unit, who served as controls.
Measurements and Results
Data for blood gas analysis, lactate, glucose, serum creatinine, bilirubin, white blood cells, platelets, and C-reactive protein were obtained from patient files on admission or at time of diagnosis of septic shock and at 7:00 a.m. on days 2 and 4; Sequential Organ Failure Assessment scores were calculated and 28-day survival was assessed. With implementation of the SOP, use of dobutamine (12/30 vs. 2/30), insulin (blood glucose <150 mg/dL, day 4: 26/28 vs. 13/25), hydrocortisone (30/30 vs. 13/30), and rhAPC (7/30 vs. 0/30) significantly increased, whereas volume for resuscitation and use of packed red blood cells were unaffected. Mortality was 53% in the historical control group and 27% after implementation of the SOP (p < .05).
Conclusion
The combined approach of early goal-directed therapy, intensive insulin therapy, hydrocortisone administration, and additional application of rhAPC in selected cases seems to favorably influence outcome. The implementation of a “sepsis bundle” can be facilitated by a standardized protocol while significantly reducing the time until the defined therapeutic measures are realized in daily practice.
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