Morceaux choisis de la littérature expérimentale

Date du colloque&nbsp;: 01/2009</p

Réanimation hépatosplanchnique

Dans l\u27histoire de la réanimation, la réanimation hépatosplanchnique est un domaine de développement récent. Les concepts physiopathologiques et les thérapeutiques sont en effet en pleine mutation. Divisé en trois parties, l\u27ouvrage présente tout d\u27abord les différentes formes de l\u27insuffisance hépatocellulaire et les principes de leur prise en charge. Il fait ensuite le point sur les cirrhoses du foie, avant d\u27approfondir la réanimation du territoire hépatosplanchnique. Les questions cliniques quotidiennes sont bien entendu abordées, sans que soient négligés les concepts théoriques, allant de la prévention des hémorragies digestives en réanimation ou de la prise en charge des complications digestives en oncohématologie jusqu\u27aux concepts les plus récents sur la translocation bactérienne ou les concepts d\u27hémodynamique splanchnique. Cet ouvrage, signé par des experts français et internationaux, s\u27attache à démontrer l\u27importance des avancées obtenues ces vingt dernières années dans la prise en charge des maladies graves du foie et de la circulation splanchnique. Il est aussi l\u27illustration de leurs limites et des progrès restant à faire pour obtenir de réelles avancées thérapeutiques. À l\u27interface de plusieurs disciplines, Réanimation hépatosplanchnique intéressera donc non seulement les réanimateurs dans leur ensemble médicaux, chirurgicaux ou spécialisés en chirurgie cardiothoracique , mais aussi les hépato-gastroentérologues, les oncologues et infectiologues

The effects of vasopressin and its analogues on the liver and its disorders in the critically ill:

Purpose of review: Vasopressin and terlipressin, a long-acting V1a analogue, are increasingly used in intensive care. The main clinical indications are the treatment of patients with septic shock and of patients with cirrhosis, who develop variceal bleeding, the hepatorenal syndrome or both. In this review, we summarize the effects of these drugs on splanchnic hemodynamics and organ function.Recent findings: A recent systematic meta-analysis of randomized trials suggests that terlipressin may improve renal function in hepatorenal syndrome and thereby reduce mortality by 34%. Moreover, a recent study reported that association of terlipressin and albumin was more effective than terlipressin alone. In patients with variceal bleeding, the bleeding control is significantly improved by early administration of terlipressin. The place of vasopressin in the treatment of patients with septic shock is still discussed, but compared with norepinephrine, vasopressin showed at least an equal efficacy. Summary: The use of vasopressin and its synthetic analogues has shown beneficial effects in the management of patients with cirrhosis, especially in the context of variceal bleeding, the hepatorenal syndrome or both. In both cases, the use of terlipressin improved survival. Therefore, in these clinical indications, terlipressin is a part of recommendations. The role of vasopressin in patients with septic shock remains to be precisely evaluated

Vasopressin and ischaemic heart disease: more than coronary vasoconstriction?

During advanced vasodilatory shock, arginine vasopressin (AVP) is increasingly used to restore blood pressure and thus to reduce catecholamine requirements. The AVP-related rise in mean arterial pressure is due to systemic vasoconstriction, which, depending on the infusion rate, may also reduce coronary blood flow despite an increased coronary perfusion pressure. In a murine model of myocardial ischaemia, Indrambarya and colleagues now report that a 3-day infusion of AVP decreased the left ventricular ejection fraction, ultimately resulting in increased mortality, and thus compared unfavourably with a standard treatment using dobutamine. The AVP-related impairment myocardial dysfunction did not result from the increased left ventricular afterload but from a direct effect on cardiac contractility. Consequently, the authors conclude that the use of AVP should be cautioned in patients with underlying cardiac disease