Fewer Episodes of Atrial Fibrillation When Vasopressin Is Combined with Norepinephrine

Association of Vasopressin Plus Catecholamine Vasopressors vs Catecholamines Alone With Atrial Fibrillation in Patients With Distributive ShockA Systematic Review and Meta-analysis

Alexandra P. Lengyel¹; Ludhmila Hajjar, MD²; Anthony C. Gordon, MD^3,4; François Lamontagne, MD, MSc⁵; Jeff S. Healey, MD, MSc¹; Richard P. Whitlock, MD, PhD¹; Emilie P. Belley-Côté, MD, MSc¹

JAMA. 2018;319(18):1889-1900. doi:10.1001/jama.2018.4528

Results  Twenty-three randomized clinical trials were identified (3088 patients; mean age, 61.1 years [14.2]; women, 45.3%). High-quality evidence supported a lower risk of atrial fibrillation associated with vasopressin treatment (RR, 0.77 [95% CI, 0.67 to 0.88]; risk difference [RD], −0.06 [95% CI, −0.13 to 0.01]). For mortality, the overall RR estimate was 0.89 (95% CI, 0.82 to 0.97; RD, −0.04 [95% CI, −0.07 to 0.00]); however, when limited to trials at low risk of bias, the RR estimate was 0.96 (95% CI, 0.84 to 1.11). The overall RR estimate for RRT was 0.74 (95% CI, 0.51 to 1.08; RD, −0.07 [95% CI, −0.12 to −0.01]). However, in an analysis limited to trials at low risk of bias, RR was 0.70 (95% CI, 0.53 to 0.92, P for interaction = .77). There were no significant differences in the pooled risks for other outcomes.

Conclusions and Relevance  In this systematic review and meta-analysis, the addition of vasopressin to catecholamine vasopressors compared with catecholamines alone was associated with a lower risk of atrial fibrillation. Findings for secondary outcomes varied.

Alternatives to the Swan–Ganz catheter

While the pulmonary artery catheter (PAC) is still interesting in specific situations, there are many alternatives. A group of experts from different backgrounds discusses their respective interests and limitations of the various techniques and related measured variables. The goal of this review is to highlight the conditions in which the alternative devices will suffice and when they will not or when these alternative techniques can provide information not available with PAC. The panel concluded that it is useful to combine different techniques instead of relying on a single one and to adapt the “package” of interventions to the condition of the patient. As a first step, the clinical and biologic signs should be used to identify patients with impaired tissue perfusion. Whenever available, echocardiography should be performed as it provides a rapid and comprehensive hemodynamic evaluation. If the patient responds rapidly to therapy, either no additional monitoring or pulse wave analysis (allowing continuous monitoring in case potential degradation is anticipated) can be applied. If the patient does not rapidly respond to therapy or complex hemodynamic alterations are observed, pulse wave analysis coupled with TPTD is suggested

Several articles are attached regarding volume management, revoiew of clinical parameters, as well as still a small role for CVP ( as long as the physiology of what CVP means is understood)monitoring, and critical role echocardiography appears to play in early management of septic shock .

Articles:

1) Alternatives to the Swan -Ganz Catheter

2) Expert Statement for the Management of Hypovolemia in Sepsis

3) Should we measure the CVP to guide fluid management: Ten answers to 10 questions

4) TTE and Mortality in Sepsis

5) Lactate Guided ResuscitationSaves Lives: no ( Editorial)

Please see my next entry in this blog for an extended discussion and the problems with lactate guided therapy in sepsis.

Links to Noninvasive and Minimally Invasive Devices mentioned in the above articles

ClearSight system

Flotrac on EV1000 clinical platform

EV1000 Brochure

The relationship between ICU hypotension and in-hospital mortality and morbidity in septic patients

The Surviving Sepsis Guidelines suggest keeping mean arterial pressure initially above 65 mmHg, followed by individualized treatment to optimize tissue perfusion. In our analysis, risks for mortality, AKI and myocardial injury were apparent by 85  mmHg, and for mortality and AKI risk progressively worsened at lower thresholds. Until randomized trials show that the relationship between hypotension and serious complications is not causal, it would probably be prudent to keep mean arterial pressure well above 65  mmHg in septic ICU patients.


The relationship between ICUhypotension and in-hospital mortalityand morbidity in septic patients

Kamal Maheshwari1,7*, Brian H. Nathanson2 , Sibyl H. Munson3 , Victor Khangulov3 , Mitali Stevens4 , Hussain Badani3 , Ashish K. Khanna5 and Daniel I. Sessler6

Author details 1 Department of Outcomes Research, Center for Perioperative Intelligence, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA. 2 OptiStatim, LLC, Longmeadow, MA, USA. 3 Department of Health Economics and Outcomes Research, Boston Strategic Partners, Inc., Boston, MA, USA. 4 Edwards Lifesciences, Irvine, CA, USA. 5 Department of Outcomes Research, Center for Critical Care, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA. 6 Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA. 7 Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, 9500 Euclid Avenue, E-31, Cleveland, OH 44195, USA.

Transthoracic echocardiography and mortality in sepsis

The performance of TTE is associated with a 28-day mortality beneft in a general population of septic, critically ill patients. The mechanism of this beneft remains to be explored but may be related to the increased use of fuids and vasoactive agents as indicated and guided by TTE results. Given that for most of ICU practice, randomized controlled trial (RCT)-based data are lacking and no RCT will likely be performed to provide evidence in the future, the application of the real-world data that is captured in EHRs is necessary to assess the clinical efectiveness of interventions such as TTE. While these investigations must be performed with full awareness of and attention to the complexity, and possible confounding by indication, of such data applications, they are now quite feasible and, we feel, absolutely necessary in the future development and evolution of optimal clinical care.


Transthoracic echocardiographyand mortality in sepsis: analysis of the MIMIC-IIIdatabase

Mengling Feng1 , Jakob I. McSparron2*, Dang Trung Kien1 , David J. Stone3 , David H. Roberts4 , Richard M. Schwartzstein4 , Antoine Vieillard‑Baron5 and Leo Anthony Celi4,6 © 2018 Springer-Verlag GmbH Germany, part of Springer Nature and ESICM