Microcirculation improvement after short-term infusion of vasopressin in septic shock is dependent on noradrenaline

OBJECTIVES: To assess the impact of vasopressin on the microcirculation and to develop a predictive model to estimate the probability of microcirculatory recruitment in patients with septic shock. METHODS: This prospective interventional study included patients with septic shock receiving noradrenaline for less than 48 hours. We infused vasopressin at 0.04 U/min for one hour. Hemodynamic measurements, including sidestream dark-field imaging, were obtained immediately before vasopressin infusion, 1 hour after vasopressin infusion and 1 hour after vasopressin withdrawal. We defined patients with more than a 10% increase in total vascular density and perfused vascular density as responders. ClinicalTrials.gov: NCT02053675. RESULTS: Eighteen patients were included, and nine (50%) showed improved microcirculation after infusion of vasopressin. The noradrenaline dose was significantly reduced after vasopressin (p=0.001) and was higher both at baseline and during vasopressin infusion in the responders than in the non-responders. The strongest predictor for a favorable microcirculatory response was the dose of noradrenaline at baseline (OR=4.5; 95% CI: 1.2-17.0; p=0.027). For patients using a noradrenaline dose higher than 0.38 mcg/kg/min, the probability that microcirculatory perfusion would be improved with vasopressin was 53% (sensitivity 78%, specificity 77%). CONCLUSIONS: In patients with septic shock for no longer than 48 h, administration of vasopressin is likely to result in an improvement in microcirculation when the baseline noradrenaline dose is higher than 0.38 mcg/kg/min

Comparação de valores de lactato obtidos em diferentes sítios e sua importância clínica em pacientes com sepse grave

CONTEXT AND OBJECTIVE: The ideal site for lactate collection has not been clearly established. This study aimed to evaluate associations between lactate levels in arterial blood (Lart), peripheral venous blood (Lper) and central venous blood (Lean) in patients with severe sepsis or septic shock.DESIGN AND SETTING: Cross-sectional analytical study in an tertiary university hospital.METHOD: Samples from patients with a central venous catheter and from healthy volunteers (control group) were collected. Blood was drawn simultaneously for measurements of Lart, Lper and Lcen, and the first sample was collected less than 24 hours after the onset of organ dysfunction. The results were analyzed using Pearson correlation, Bland-Altman and McNemar tests.RESULTS: A total of 238 samples were collected from 32 patients. The correlation results were r = 0.79 (P < 0.0001) for Lart/Lper and r = 0.84 (P < 0.0001) for Lart/Lcen. Bland-Altman showed large limits of agreement: -3.2 +/- 4.9 (-12.8 to 6.4) and -0.8 +/- 5.9 (-12.5 to 10.8), for Lper and Lcen respectively. lathe control group, there was greater correlation (r = 0.9009, P = 0.0004) and agreement: -0.7 +/- 1.2 (-3.1 to 1.7). Regarding clinical intervention, there was good agreement between Lart/Lcen (96.3%; three disagreements), with worst results for Lart/Lper (87.0%) with 10 cases of disagreement (P = 0.04). In eight patients (80.0%) Lper was higher than Lart.CONCLUSION: Lcen, and not Lper, can replace Lart with good correlation and clinical agreement. Lper tends to overestimate Lart, thus leading to unnecessary therapeutic interventions.Univ Fed Sao Paulo Escola Paulista Med Unifesp EP, Intens Care Unit, Discipline Anesthesiol Pain & Intens Care, Sao Paulo, BrazilUniv Fed Sao Paulo Escola Paulista Med Unifesp EP, Intens Care Unit, Discipline Anesthesiol Pain & Intens Care, Sao Paulo, BrazilWeb of Scienc

Hemodynamic effects of low-dose arginine vasopressin in septic shock

A vasopressina é um dos vasopressores utilizados em pacientes com choque séptico. No entanto, os seus efeitos hemodinâmicos sistêmicos e microcirculatórios não são completamente conhecidos e compreendidos. Este estudo teve como objetivo avaliar os efeitos da vasopressina exógena na microcirculação sublingual, utilizando a técnica de sidestream dark field, e correlacionar estes potenciais achados com os efeitos sistêmicos da mesma. Neste estudo prospectivo com intervenção, foram incluídos pacientes com choque séptico, nas primeiras 48 horas de uso de catecolaminas vasopressoras, internados nas unidades de terapia intensiva da Disciplina de Anestesiologia, Dor e Terapia Intensiva da Universidade Federal de São Paulo. A vasopressina foi administrada a 0,04 U/min por uma hora. Foram obtidas medidas hemodinâmicas sistêmicas, imediatamente antes e 1 hora após o início da vasopressina. Além disso, imagens de microcirculação sublingual foram coletadas por meio da tecnologia de sidestream dark field, para posterior análise com software específico. Após inclusão de 18 pacientes, observou-se redução significativa da dose de catecolaminas após a vasopressina (0,41 μg/kg/min (0,23 - 0,90) versus 0,31 μg/kg/min (0,09 - 0,76), p = 0,001). Verificou-se redução da frequência cardíaca, índice sistólico, índice cardíaco, bem como da saturação venosa mista e alargamento do gradiente venoso-arterial de pCO2 (p = 0,009, 0,022, 0,002, 0,044 e 0,039, respectivamente). No entanto, houve redução dos níveis de lactato (30,3 ± 17,3 mg/dL versus 27,6 ± 15,8 mg/dL, p = 0,037) e não ocorreu alteração significativa na densidade vascular total, densidade de vasos perfundidos, proporção de vasos perfundidos, índice de fluxo microcirculatório e índice de heterogeneidade (p > 0,05 para todos). Encontrou-se correlação negativa entre a variação de três dos parâmetros da microcirculação e seu respectivo valor basal: densidade vascular total (r = - 0,670; p = 0,002), densidade vascular perfundida (r= - 0,71; p = 0,001) e proporção de vasos perfundidos (r = - 0,531; p = 0,023). Porém, não houve correlação entre estas variações e o índice cardíaco basal (r=- 0,100; p = 0,692 para densidade vascular total; r = - 0,204; p = 0,418 para densidade vascular perfundida; r = - 0,369; p = 0,132 para proporção de vasos perfundidos; r = 0,200; p = 0,425 para índice de fluxo microcirculatório e r = 0,106; p = 0,675 para índice de heterogeneidade). Desta forma, o presente estudo sugere que, embora a vasopressina esteja relacionada a efeitos potencialmente prejudiciais à macrocirculação, sua associação a catecolaminas vasopressoras proporciona redução da dose dos mesmos, sem impacto significativo na rede microcirculatória. Por outro lado, houve melhora dos parâmetros da microcirculação nos pacientes que os apresentaram comprometidos antes do início da infusão de vasopressina.Vasopressin is one of the vasopressor used in patients with septic shock. However, its systemic hemodynamic effects and its microcirculation effects are not completely known. This study aimed to evaluate the effects of exogenous vasopressin on sublingual microcirculation using sidestream dark field technique and to correlate them with its systemic effects. We included in this prospective interventional study patients with septic shock admitted to the intensive care unit of the Departamento de Anestesiologia, Dor e Terapia Intensiva from Universidade Federal de São Paulo, during the first 48 hours of use of catecholamine vasopressors. Vasopressin was administered at 0.04 U/min for one hour. Systemic hemodynamic measurements were obtained immediately before and 1 hour after vasopressin. In addition, images of sublingual microcirculation were collected through sidestream dark field technology and analyzed with specific software. After the inclusion of 18 patients, we found a significant reduction in catecholamine’s dose after vasopressin (0.41 mg/kg/min (0.23 to 0.90) versus 0.31 ug/kg/min (0.09 to 0.76) p = 0.001). There were also a reduction in heart rate, stroke volume index, cardiac index, and mixed venous saturation and an increase in venous-arterial pCO2 gradient (p = 0.009, 0.022, 0.002, 0.044 and 0.039, respectively). However, lactate levels decreased (30.3 ± 17.3 mg/dL versus 27.6 ± 15.8 mg/dL, p = 0.037) and there was no significant change in the total vascular density, perfused vessel density, proportion of perfused vessels, microcirculatory flow index and heterogeneity index (p> 0.05 for all). We also found a significant negative correlation between the variation of three microcirculation parameters and their respective baseline values - total vascular density (r = - 0.670, p = 0.002), perfused vessel density (r = - 0.71, p = 0.001) and proportion of perfused vessels (r = - 0.531, p = 0.023). However, there was no correlation between these variation and the baseline cardiac index (r = - 0.100, p = 0.692 for total vascular density, r = - 0.204, p = 0.418 for perfused vascular density, r = - 0.369, p = 0.132 for proportion of perfused vessels, r = 0.200, p = 0.425 for microcirculatory flow index, r = 0.106, p = 0.675 for heterogeneity index). In conclusion, this study suggested that, although vasopressin was associated with potentially harmful effects on macrocirculation, its use in association with catecholamine vasopressors provides reduction in catecholamine’s dose without significant impact on the microcirculatory network. In addition, in patients with worst baseline microcirculatory parameters, there was an improvement in microcirculation after vasopressin infusion.BV UNIFESP: Teses e dissertaçõe

Diabetes mellitus e intolerância à glicose são subdiagnosticados nas unidades de terapia intensiva

OBJETIVO: Avaliar a presença de diabetes mellitus e a intolerância à glicose em pacientes internados em unidades de terapia intensiva. MÉTODOS: Foram incluídos pacientes clínicos, em pós-operatório de cirurgias eletivas e de urgência, e excluídos aqueles com história de diabetes mellitus. Para o diagnóstico de alterações prévias da glicemia, utilizou-se a dosagem da hemoglobina glicada (HbA1c) na admissão do paciente, sendo classificado em normal (<5,7%), intolerante à glicose (5,7-6,4%) ou diabético (&gt;6,4%). Durante os 3 primeiros dias da internação, foram avaliados o controle glicêmico e as complicações clínicas. A evolução para óbito foi acompanhada por 28 dias. Para as análises estatísticas, utilizaram-se testes do qui-quadrado, ANOVA, teste t de Student, Kruskall-Wallis ou Mann Whitney. RESULTADOS: Foram incluídos 30 pacientes, 53% do gênero feminino, idade de 53,4±19,7 anos e APACHE II de 13,6±6,6. A maioria dos pacientes foi admitida por sepse grave ou choque séptico, seguido por pós-operatório de cirurgias eletivas, oncológicas, politraumatismo e cirurgia de urgência. Ao classificar esses pacientes segundo a HbA1c, apesar da ausência prévia de história de diabetes mellitus, apenas 13,3% tinham HbA1c normal, 23,3% tinham níveis compatíveis com o diagnóstico de diabetes mellitus e 63,3% eram compatíveis com intolerância à glicose. Houve associação significativa entre o diagnóstico de diabetes mellitus ou intolerância a glicose e o uso de droga vasoativa (p=0,04). CONCLUSÃO: Foi encontrada alta prevalência de diabetes mellitus e intolerância à glicose, sem diagnóstico prévio, em pacientes internados em uma unidade de terapia intensiva geral

Microcirculation improvement after short-term infusion of vasopressin in septic shock is dependent on noradrenaline

OBJECTIVES: To assess the impact of vasopressin on the microcirculation and to develop a predictive model to estimate the probability of microcirculatory recruitment in patients with septic shock. METHODS: This prospective interventional study included patients with septic shock receiving noradrenaline for less than 48 hours. We infused vasopressin at 0.04 U/min for one hour. Hemodynamic measurements, including sidestream dark-field imaging, were obtained immediately before vasopressin infusion, 1 hour after vasopressin infusion and 1 hour after vasopressin withdrawal. We defined patients with more than a 10% increase in total vascular density and perfused vascular density as responders. ClinicalTrials.gov: NCT02053675. RESULTS: Eighteen patients were included, and nine (50%) showed improved microcirculation after infusion of vasopressin. The noradrenaline dose was significantly reduced after vasopressin (p=0.001) and was higher both at baseline and during vasopressin infusion in the responders than in the non-responders. The strongest predictor for a favorable microcirculatory response was the dose of noradrenaline at baseline (OR=4.5; 95% CI: 1.2-17.0; p=0.027). For patients using a noradrenaline dose higher than 0.38 mcg/kg/min, the probability that microcirculatory perfusion would be improved with vasopressin was 53% (sensitivity 78%, specificity 77%). CONCLUSIONS: In patients with septic shock for no longer than 48 h, administration of vasopressin is likely to result in an improvement in microcirculation when the baseline noradrenaline dose is higher than 0.38 mcg/kg/min

Microcirculation improvement after short-term infusion of vasopressin in septic shock is dependent on noradrenaline

textabstractOBJECTIVES: To assess the impact of vasopressin on the microcirculation and to develop a predictive model to estimate the probability of microcirculatory recruitment in patients with septic shock. METHODS: This prospective interventional study included patients with septic shock receiving noradrenaline for less than 48 hours. We infused vasopressin at 0.04 U/min for one hour. Hemodynamic measurements, including sidestream dark-field imaging, were obtained immediately before vasopressin infusion, 1 hour after vasopressin infusion and 1 hour after vasopressin withdrawal. We defined patients with more than a 10% increase in total vascular density and perfused vascular density as responders. ClinicalTrials.gov: NCT02053675. RESULTS: Eighteen patients were included, and nine (50%) showed improved microcirculation after infusion of vasopressin. The noradrenaline dose was significantly reduced after vasopressin (p=0.001) and was higher both at baseline and during vasopressin infusion in the responders than in the non-responders. The strongest predictor for a favorable microcirculatory response was the dose of noradrenaline at baseline (OR=4.5; 95% CI: 1.2-17.0; p=0.027). For patients using a noradrenaline dose higher than 0.38 mcg/kg/min, the probability that microcirculatory perfusion would be improved with vasopressin was 53% (sensitivity 78%, specificity 77%). CONCLUSIONS: In patients with septic shock for no longer than 48 h, administration of vasopressin is likely to result in an improvement in microcirculation when the baseline noradrenaline dose is higher than 0.38 mcg/kg/min