Phenylephrine versus norepinephrine for initial hemodynamic support of patients with septic shock: a randomized, controlled trial

Previous findings suggest that a delayed administration of phenylephrine replacing norepinephrine in septic shock patients causes a more pronounced hepatosplanchnic vasoconstriction as compared with norepinephrine. Nevertheless, a direct comparison between the two study drugs has not yet been performed. The aim of the present study was, therefore, to investigate the effects of a first-line therapy with either phenylephrine or norepinephrine on systemic and regional hemodynamics in patients with septic shock. METHODS: We performed a prospective, randomized, controlled trial in a multidisciplinary intensive care unit in a university hospital. We enrolled septic shock patients (n = 32) with a mean arterial pressure below 65 mmHg despite adequate volume resuscitation. Patients were randomly allocated to treatment with either norepinephrine or phenylephrine infusion (n = 16 each) titrated to achieve a mean arterial pressure between 65 and 75 mmHg. Data from right heart catheterization, a thermodye dilution catheter, gastric tonometry, acid-base homeostasis, as well as creatinine clearance and cardiac troponin were obtained at baseline and after 12 hours. Differences within and between groups were analyzed using a two-way analysis of variance for repeated measurements with group and time as factors. Time-independent variables were compared with one-way analysis of variance. RESULTS: No differences were found in any of the investigated parameters. CONCLUSIONS: The present study suggests there are no differences in terms of cardiopulmonary performance, global oxygen transport, and regional hemodynamics when phenylephrine was administered instead of norepinephrine in the initial hemodynamic support of septic shock

Continuous terlipressin versus vasopressin infusion in septic shock (TERLIVAP): a randomized, controlled pilot study

Introduction Recent clinical data suggest that early administration of vasopressin analogues may be advantageous compared to a last resort therapy. However, it is still unknown whether vasopressin and terlipressin are equally effective for hemodynamic support in septic shock. The aim of the present prospective, randomized, controlled pilot trial study was, therefore, to compare the impact of continuous infusions of either vasopressin or terlipressin, when given as first-line therapy in septic shock patients, on open-label norepinephrine requirements. Methods We enrolled septic shock patients (n = 45) with a mean arterial pressure below 65 mmHg despite adequate volume resuscitation. Patients were randomized to receive continuous infusions of either terlipressin (1.3 mu g.kg(-1).h(-1)), vasopressin (.03U.min(-1)) or norepinephrine (15 mu g.min(-1); n = 15 per group). In all groups, open-label norepinephrine was added to achieve a mean arterial pressure between 65 and 75 mmHg, if necessary. Data from right heart and thermo-dye dilution catheterization, gastric tonometry, as well as laboratory variables of organ function were obtained at baseline, 12, 24, 36 and 48 hours after randomization. Differences within and between groups were analyzed using a two-way ANOVA for repeated measurements with group and time as factors. Time-independent variables were compared with one-way ANOVA. Results There were no differences among groups in terms of systemic and regional hemodynamics. Compared with infusion of .03U of vasopressin or 15 mu g.min(-1) of norepinephrine, 1.3 mu g.kg(-1).h(-1) of terlipressin allowed a marked reduction in catecholamine requirements (0.8 +/- 1.3 and 1.2 +/- 1.4 vs. 0.2 +/- 0.4 mu g.kg(-1).min(-1) at 48 hours; each P < 0.05) and was associated with less rebound hypotension (P < 0.05). At the end of the 48-hour intervention period, bilirubin concentrations were higher in the vasopressin and norepinephrine groups as compared with the terlipressin group (2.3 +/- 2.8 and 2.8 +/- 2.5 vs. 0.9 +/- 0.3 mg.dL(-1); each P < 0.05). A time-dependent decrease in platelet count was only observed in the terlipressin group (P < 0.001 48 hours vs. BL). Conclusions The present study provides evidence that continuous infusion of low-dose terlipressin - when given as first-line vasopressor agent in septic shock - is effective in reversing sepsis-induced arterial hypotension and in reducing norepinephrine requirements

Microvascular Effects of Heart Rate Control With Esmolol in Patients With Septic Shock: A Pilot Study*

none14β-blocker therapy may control heart rate and attenuate the deleterious effects of β-stimulating catecholamines in septic shock. However, their negative chronotropy and inotropy may potentially lead to an inappropriately low cardiac output, with a subsequent compromise of microvascular blood flow. The purpose of the present pilot study was to investigate the effects of reducing heart rate to less than 95 beats per minute in patients with septic shock using the β-1 adrenoceptor blocker, esmolol, with specific focus on systemic hemodynamics and the microcirculation.Prospective, observational clinical study.Multidisciplinary ICU at a university hospital.After 24 hours of initial hemodynamic optimization, 25 septic shock patients with a heart rate greater than or equal to 95 beats per minute and requiring norepinephrine to maintain mean arterial pressure greater than or equal to 65 mm Hg received a titrated esmolol infusion to maintain heart rate less than 95 beats per minute. Sublingual microcirculatory blood flow was assessed by sidestream dark-field imaging. All measurements, including data from right heart catheterization and norepinephrine requirements, were obtained at baseline and 24 hours after esmolol administration. Heart rates targeted between 80 and 94 beats per minute were achieved in all patients. Whereas cardiac index decreased (4.0 [3.5; 5.3] vs 3.1 [2.6; 3.9] L/min/m; p < 0.001), stroke volume remained unchanged (34 [37; 47] vs 40 [31; 46] mL/beat/m; p = 0.32). Microcirculatory blood flow in small vessels increased (2.8 [2.6; 3.0] vs 3.0 [3.0; 3.0]; p = 0.002), while the heterogeneity index decreased (median 0.06 [interquartile range 0; 0.21] vs 0 [0; 0]; p = 0.002). PaO2 and pH increased while PaCO2 decreased (all p < 0.05). Of note, norepinephrine requirements were significantly reduced by selective β-1 blocker therapy (0.53 [0.29; 0.96] vs 0.41 [0.22; 0.79] µg/kg/min; p = 0.03).This pilot study demonstrated that heart rate control by a titrated esmolol infusion in septic shock patients was associated with maintenance of stroke volume, preserved microvascular blood flow, and a reduction in norepinephrine requirements.A. Morelli;A. Donati;C. Ertmer;S. Rehberg;T. Kampmeier;A. Orecchioni;A. D'Egidio;V. Cecchini;G. Landoni;P. Pietropaoli;M. Westphal;M. Venditti;A. Mebazaa;M. SingerA., Morelli; Donati, Abele; C., Ertmer; S., Rehberg; T., Kampmeier; A., Orecchioni; A., D'Egidio; V., Cecchini; G., Landoni; P., Pietropaoli; M., Westphal; M., Venditti; A., Mebazaa; M., Singe

Effects of vasopressinergic receptor agonists on sublingual microcirculation in norepinephrine-dependent septic shock.

none15ABSTRACT: INTRODUCTION: The present study was designed to determine the effects of continuously infused norepinephrine (NE) plus (1) terlipressin (TP) or (2) arginine vasopressin (AVP) or (3) placebo on sublingual microcirculation in septic shock patients. The primary study end point was a difference of ≥ 20\% in the microvascular flow index of small vessels among groups. METHODS: The design of the study was a prospective, randomized, double-blind clinical trial. NE was titrated to maintain mean arterial pressure (MAP) between 65 and 75 mmHg after establishment of normovolemia in 60 septic shock patients. Thereafter patients (n = 20 per group) were randomized to receive continuous infusions of either TP (1 μg/kg/hour), AVP (0.04 U/minute) or placebo (isotonic saline). In all groups, open-label NE was adjusted to maintain MAP within threshold values if needed. The sublingual microcirculatory blood flow of small vessels was assessed by sidestream dark-field imaging. All measurements, including data from right heart catheterization and norepinephrine requirements, were obtained at baseline and 6 hours after randomization. RESULTS: TP and AVP decreased NE requirements at the end of the 6-hour study period. The data are medians (25th and 75th interquartile ranges (IQRs)): 0.57 μg/kg/minute (0.29 to 1.04) vs. 0.16 μg/kg/minute (0.03 to 0.37) for TP and 0.40 μg/kg/minute (0.20 to 1.05) vs. 0.23 μg/kg/minute (0.03 to 0.77) for AVP, with statistical significance of P < 0.05 vs. baseline and vs. placebo. There were no differences in sublingual microcirculatory variables, systemic hemodynamics, oxygen transport and acid-base homeostasis among the three study groups during the entire observation period. The proportions of perfused vessels increased in relation to baseline within all study groups, and there were no significant differences between groups. The specific data were as follows (median (IQR)): 9.7\% (2.6 to 19.8) for TP, 8.9\% (0.0 to 17.8) for AVP, and 6.9\% (3.5 to 10.1) for placebo (P < 0.05 vs. baseline for each comparison), as well as perfused vessel density 18.6\% (8.6 to 36.9) for TP, 20.2\% (-3.0 to 37.2) for AVP, and 11.4\% (-3.0 to 19.4) for placebo (P < 0.05 vs. baseline for each comparison). CONCLUSIONS: The present study suggests that to achieve a MAP of 65 to 75 mmHg in septic patients treated with NE, the addition of continuously infused low-dose TP or AVP does not affect sublingual microcirculatory blood flow. In addition, our results suggest that microcirculatory flow abnormalities are mainly related to other factors (for example, volume status, timing, hemodynamics and progression of the disease) rather than to the vasopressor per se. TRIAL REGISTRATION: ClinicalTrial.gov NCT00995839.A. Morelli;A. Donati;C. Ertmer;S. Rehberg;T. Kampmeier;A. Orecchioni;A. D. Russo;A. D'Egidio;G. Landoni;M. R. Lombrano;L. Botticelli;A. Valentini;A. Zangrillo;P. Pietropaoli;M. WestphalA., Morelli; Donati, Abele; C., Ertmer; S., Rehberg; T., Kampmeier; A., Orecchioni; A. D., Russo; A., D'Egidio; G., Landoni; M. R., Lombrano; L., Botticelli; A., Valentini; A., Zangrillo; P., Pietropaoli; M., Westpha

Chemical evidence for the persistence of wine production and trade in Early Medieval Islamic Sicily

As a high-value luxury commodity, wine has been transported across the Mediterranean since the Bronze Age. The wine trade was potentially disrupted during political and religious change brought about by Islamization in the Early Medieval period; wine consumption is prohibited in Islamic scripture. Utilizing a quantitative criterion based on the relative amounts of two fruit acids in transport amphorae, we show that wine was exported from Sicily beyond the arrival of Islam in the ninth century, including to Christian regions of the central Mediterranean. This finding is significant for understanding how regime change affected trade in the Middle Ages. We also outline a robust analytical approach for detecting wine in archaeological ceramics that will be useful elucidating viniculture more broadly.Although wine was unquestionably one of the most important commodities traded in the Mediterranean during the Roman Empire, less is known about wine commerce after its fall and whether the trade continued in regions under Islamic control. To investigate, here we undertook systematic analysis of grapevine products in archaeological ceramics, encompassing the chemical analysis of 109 transport amphorae from the fifth to the eleventh centuries, as well as numerous control samples. By quantifying tartaric acid in relation to malic acid, we were able to distinguish grapevines from other fruit-based products with a high degree of confidence. Using these quantitative criteria, we show beyond doubt that wine continued to be traded through Sicily during the Islamic period. Wine was supplied locally within Sicily but also exported from Palermo to ports under Christian control. Such direct evidence supports the notion that Sicilian merchants continued to capitalize on profitable Mediterranean trade networks during the Islamic period, including the trade in products prohibited by the Islamic hadiths, and that the relationship between wine and the rise of Islam was far from straightforward.All study data are included in the article and/or SI Appendix

Sicily in Transition : Interim report of investigations at Castronovo di Sicilia 2016

La città di Castronovo di Sicilia (PA) e i suoi dintorni sono attualmente oggetto di ricerche archeologiche condotte dalle università di York, Roma e Lecce in collaborazione con la Soprintendenza per i Beni culturali e ambientali di Palermo e con il sostegno del Comune di Castronovo. Quattro diversi insediamenti sono stati indagati per mezzo di prospezioni e scavi. Sul Monte Kassar, interpretabile, allo stato attuale delle ricerche, come una fortezza bizantina dell’ VIII–IX secolo, nel 2015 sono state individuate strutture con funzione abitativa all’interno e in appoggio alle fortificazioni, mentre nel 2016 sono stati scavati i resti di una “casaforte” (la cosiddetta “casermetta"). Sul Colle San Vitale, i ruderi delle strutture medievali ancora in piedi sono stati oggetto di una prospezione di alta precisione, come anche la città vecchia di Castronovo, dove anche sono stati individuate e cartografate le acque sotterranee e un sistema di irrigazione. Infine, a Casale San Pietro, nella pianura vicino a Castronovo e sulle rive del fiume Platani, un insediamento esteso di epoca tardoromana e bizantina (orientativamente dei secoli V–VII secolo) è stato parzialmente identificato attraverso prospezioni geofisiche, raccolte di superficie e sondaggi. Nel 2015 e 2016 è stato possibile dimostrare in un’area di scavo (Int 5) che l’insediamento di epoca bizantina (la cosiddetta agro-town) è stato rioccupato da uno di epoca islamica e normanna (IX–XII secolo). L’attuale campagna di ricerche sul Medioevo nel Comune di Castronovo di Sicilia (PA) è stata avviata nel 2014 e proseguita nel 2015. Nel corso del 2016, queste indagini hanno assunto un ruolo centrale nel progetto più ampio finanziato dall’European Research Council (SICTRANSIT). L’obiettivo centrale di questo progetto è di comprendere il carattere delle trasformazioni economiche, ambientali e sociali dell’intera Sicilia tra il VI e il XIII secolo . La relazione che segue presenta i risultati ottenuti nel 2016 a Castronovo nei quattro insediamenti principali e una breve descrizione delle ricerche in corso sulla ceramica, la fauna, e i reperti particolari effettuata dai responsabili delle loro analisi. Infine, si conclude con una valutazione del significato della campagna del 2016 e uno sguardo alle prossime tappe del progetto

Levosimendan for resuscitating the microcirculation in patients with septic shock: A randomized controlled study

__Introduction:__ The purpose of the present study was to investigate microcirculatory blood flow in patients with septic shock treated with levosimendan as compared to an active comparator drug (i.e. dobutamine). The primary end point was a difference of ≥ 20% in the microvascular flow index of small vessels (MFIs) among groups. __Methods:__ The study was designed as a prospective, randomized, double-blind clinical trial and performed in a multidisciplinary intensive care unit. After achieving normovolemia and a mean arterial pressure of at least 65 mmHg, 40 septic shock patients were randomized to receive either levosimendan 0.2 μg·kg-1·min-1(n = 20) or an active comparator (dobutamine 5 μg·kg-1·min-1; control; n = 20) for 24 hours. Sublingual microcirculatory blood flow of small and medium vessels was assessed by sidestream dark-field imaging. Microcirculatory variables and data from right heart catheterization were obtained at baseline and 24 hours after randomization. Baseline and demographic data were compared by means of Mann-Whitney rank sum test or chi-square test, as appropriate. Microvascular and hemodynamic variables were analyzed using the Mann-Whitney rank sum test. __Results:__ Microcirculatory flow indices of small and medium vessels increased over time and were significantly higher in the levosimendan group as compared to the control group; P = .02; MFIs 2.9. The relative increase of perfused vessel density vs. baseline was significantly higher in the levosimendan group than in the control group. In addition, the heterogeneity index decreased only in the levosimendan group. There was no statistically significant correlation between systemic and microcirculatory flow variables within each group. __Conclusions:__ Compared to a standard dose of 5 μg·kg-1·min-1of dobutamine, levosimendan at 0.2 μg·kg-1·min-1improved sublingual microcirculatory blood flow in patients with septic shock, as reflected by changes in microcirculatory flow indices of small and medium vessels.Trial registration: NCT00800306

Effect of Heart Rate Control With Esmolol on Hemodynamic and Clinical Outcomes in Patients With Septic Shock A Randomized Clinical Trial

IMPORTANCE β-Blocker therapy may control heart rate and attenuate the deleterious effects of β-adrenergic receptor stimulation in septic shock. However, β-Blockers are not traditionally used for this condition and may worsen cardiovascular decompensation related through negative inotropic and hypotensive effects. OBJECTIVE To investigate the effect of the short-acting β-blocker esmolol in patients with severe septic shock. DESIGN, SETTING, AND PATIENTS Open-label, randomized phase 2 study, conducted in a university hospital intensive care unit (ICU) between November 2010 and July 2012, involving patients in septic shock with a heart rate of 95/min or higher requiring high-dose norepinephrine to maintain a mean arterial pressure of 65 mm Hg or higher. INTERVENTIONS We randomly assigned 77 patients to receive a continuous infusion of esmolol titrated to maintain heart rate between 80/min and 94/min for their ICU stay and 77 patients to standard treatment. MAIN OUTCOMES AND MEASURES Our primary outcome was a reduction in heart rate below the predefined threshold of 95/min and to maintain heart rate between 80/min and 94/min by esmolol treatment over a 96-hour period. Secondary outcomes included hemodynamic and organ function measures; norepinephrine dosages at 24, 48, 72, and 96 hours; and adverse events and mortality occurring within 28 days after randomization. RESULTS Targeted heart rates were achieved in all patients in the esmolol group compared with those in the control group. The median AUC for heart rate during the first 96 hours was −28/min (IQR, −37 to −21) for the esmolol group vs −6/min (95% CI, −14 to 0) for the control group with a mean reduction of 18/min (P &lt; .001). For stroke volume index, the median AUC for esmolol was 4 mL/m 2 (IQR, −1 to 10) vs 1 mL/m 2 for the control group (IQR, −3 to 5; P = .02), whereas the left ventricular stroke work index for esmolol was 3 mL/m 2 (IQR, 0 to 8) vs 1 mL/m 2 for the control group (IQR, −2 to 5; P = .03). For arterial lactatemia, median AUC for esmolol was −0.1 mmol/L (IQR, −0.6 to 0.2) vs 0.1 mmol/L for the control group (IQR, −0.3 for 0.6; P = .007); for norepinephrine, −0.11 μg/kg/min (IQR, −0.46 to 0.02) for the esmolol group vs −0.01 μg/kg/min (IQR, −0.2 to 0.44) for the control group (P = .003). Fluid requirements were reduced in the esmolol group: median AUC was 3975 mL/24 h (IQR, 3663 to 4200) vs 4425 mL/24 h (IQR, 4038 to 4775) for the control group (P &lt; .001). We found no clinically relevant differences between groups in other cardiopulmonary variables nor in rescue therapy requirements. Twenty-eight day mortality was 49.4% in the esmolol group vs 80.5% in the control group (adjusted hazard ratio, 0.39; 95% CI, 0.26 to 0.59; P &lt; .001). CONCLUSIONS AND RELEVANCE For patients in septic shock, open-label use of esmolol vs standard care was associated with reductions in heart rates to achieve target levels, without increased adverse events. The observed improvement in mortality and other secondary clinical outcomes warrants further investigation

New insights into early medieval Islamic cuisine : Organic residue analysis of pottery from rural and urban Sicily

Sicily, during the 9th-12th century AD, thrived politically, economically, and culturally under Islamic political rule and the capital of Palermo stood as a cultural and political centre in the Mediterranean Islamic world. However, to what extent the lifeways of the people that experienced these regimes were impacted during this time is not well understood, particularly those from lesser studied rural contexts. This paper presents the first organic residue analysis of 134 cooking pots and other domestic containers dating to the 9th -12th century in order to gain new insights into the culinary practices during this significant period. Ceramics from three sites in the urban capital of Palermo and from the rural town of Casale San Pietro were analysed and compared. The multi-faceted organic residue analysis identified a range of commodities including animal products, vegetables, beeswax, pine and fruit products in the ceramics, with a complex mixing of resources observed in many cases, across all four sites and ceramic forms. Alongside the identification of commodities and how they were combined, new light has been shed on the patterning of resource use between these sites. The identification of dairy products in calcite wares from the rural site of Casale San Pietro and the absence of dairy in ceramics from the urban centre of Palermo presents interesting questions regarding the role of rural sites in food consumption and production in Islamic Sicily. This is the first time organic residue analysis of ceramics has been used to explore foodways in a medieval multi-faith society and offers new pathways to the understanding of pottery use and resources that were prepared, consumed and combined, reflecting cuisine in different socio-economic environments within the pluralistic population of medieval Sicily

Sicily in transition : new research on early medieval Sicily, 2017-2018

Il testo che segue riguarda la nostra ricerca archeologica sulla Sicilia bizantina, islamica e normanno-sveva e in particolare riporta le ultime scoperte a Castronovo di Sicilia, che includono il riconoscimento di una chiesa del XII-XIII secolo sul Monte Kassar, la continuazione dello scavo a Casale San Pietro e una sintesi delle nuove ricognizioni nelle sue vicinanze. Quest’ultimo sito rimane il focus principale del Progetto ERC sictransit, ma in questa sede diamo anche conto dei primi risultati di un’indagine più ampia, che include una grossa quantità di reperti che provengono da tutta la Sicilia da siti scavati in precedenza (Fig 1). Questi reperti consistino in ceramiche, metalli e vetri assieme a resti umani, animali e vegetali, che vengono analizzati nei laboratori delle università partner del progetto: York, Roma e Lecce. I principali metodi scientifici applicati sono: analisi tipologiche, petrografiche e del contenuto organico delle ceramiche da cucina e da trasporto; degli isotopi stabili e del DNA antico sui resti umani e animali per determinare la dieta e l’ascendenza genetica; infine la identificazione tassonomica e la caratterizzazione isotopica degli insiemi di resti botanici per comprendere le loro relazioni con il clima e con le diverse fasi storiche. Sictransit combina quindi ricerche archeologiche, bioarcheologiche e biomolecolari in un unico progetto integrato. Gli obiettivi attesi sono stati suddivisi, per comodità e chiarezza, in tre principali aree di studio, vale a dire: agricoltura (e cibo), scambi e demografia. Infine concludiamo con una valutazione della ricerca svolta sul campo e delle prospettive di indagine dei tre laboratori