An overview of regular dialysis treatment in Japan as of 31 December 2003

A statistical survey of 3750 nationwide dialysis facilities was carried out by the Japanese Society for Dialysis Therapy (JSDT) at the end of 2003, with answers to the questionnaires received from 3717 facilities (99.12%). The population of dialysis patients in Japan at the end of 2003 was 237,710, and the number of dialysis patients per million people was 1862.7. The crude death rate during a 1-year period from the end of 2002 to the end of 2003 was 9.3%. The mean age of patients newly introduced to dialysis was 65.4 years, and the mean age of the entire dialysis population was 62.3 years. The primary diseases in the patients newly introduced to dialysis in 2003 included diabetic nephropathy (41.0% of patients) and chronic glomerulonephritis (29.1% of patients). The mean serum neutral fat concentration for all the dialysis patients was 113.9 +/- 71.7 mg/dL (+/- SD). The mean serum low density lipoprotein (LDL)-cholesterol concentration was 90.8 +/- 30.9 mg/dL. Dialysate calcium concentrations ranging from 3.0 mEq/L to less than 3.5 mEq/L were used for majority of the dialysis patients (55.4%). Among anticoagulants given to the dialysis patients, heparins were the most commonly used in 79.3% of the dialysis patients. The relationship between blood pressure during dialysis and life expectancy for 1 year was analyzed for 43,465 patients who had undergone dialysis three times per week at the end of 2001. Results showed a significantly high mortality risk for patients who had systolic blood pressure of less than 100 mm Hg at the start of dialysis, systolic blood pressure of less than 100 mm Hg at the end of dialysis, and the greatest decrease (lowest) in systolic blood pressure of less than 120 mm Hg during dialysis. Patients who received vasopressor therapy during dialysis had a higher mortality risk than those who received no vasopressor therapy.     

Injector: a simple device to inject large quantities of vasopressor-anesthetic solutions

More than 500 ml of various vasopressor-anesthetic solutions are often injected prior to or during some surgical procedures. A device is presented with which one can inject large volumes of solutions into the soft tissues faster and easier than manually with a syringe. It can be constructed from parts usually found in the intensive care units or operating theaters. The device was constructed in 1990 and it was, in over 300 cases, found to be safe, reliable and easy to use. Received: 20 May 1998 / Accepted 20 July 1998     

Adrenal exhaustion in septic patients with vasopressor dependency

Purpose

The use of low-dose corticosteroids for patients with septic shock who remain vasopressor dependent after adequate fluid resuscitation is recommended, but there is lack of agreement on how to diagnose relative adrenal insufficiency (RAI) and when to start steroid supplementation among these patients. This case series reports changes in cortisol concentrations during the course of vasopressor-dependent septic shock.

Methods

Observational study was performed at a university hospital medical intensive care unit. Consecutive adult patients with vasopressor-dependent septic shock admitted to the medical intensive care unit were studied. Clinical data, cortisol concentrations, and dose of vasopressor agents at different times during the course of septic shock were recorded and reported as mean ± SD.

Results

Thirteen patients were included. Mean age was 59 ± 15 years. Mean basal nonstimulated cortisol level was 41.7 ± 30.9 μg/dL (within 24 hours of intensive care unit admission in all but 2 patients). Steroids were initiated in 8 patients and then discontinued after cortisol values were obtained and RAI was ruled out. Because of inability to discontinue vasopressor support, cortisol testing was repeated after 6.2 ± 4.8 days of initial assessment. Repeated concentrations were 10.0 ± 6.3 μg/dL (P < .001). Steroids were then reinitiated, and resolution of vasopressor dependence was achieved 1.5 ± 1.4 days later.

Conclusions

Adrenal function in the critically ill is a dynamic process, and an appropriate initial adrenal response does not preclude later development of RAI.     

Identification of vasopressor constituents of amniotic fluid in pregnancy toxaemia

Summary The vasopressor activity of human amniotic fluid was assessed in 46 primigravidas during the third trimester of pregnancy. The subjects included 20 normal and 26 cases of pregnancy toxaemia. For identification of the vasoptessor activity of the amniotic fluid, blood pressure measurements were made in the intact rat, and the smooth muscle contraction of the rat ascending colon preparation was determinedin vitro. The samples of amniotic fluid showing vasoptessor activity were lyophilized and subjected to gel filtration using Sephadex G-100. The various fractions thus obtained were monitored at 280 nm and the pressor activity was re-estimated. It was observed that most of the pressor activity of the amniotic fluid of the toxaemic patients was capable of causing contraction of the rat colon as well as a significant rise in the systolic blood pressure of the intact rat. Furthermore, this activity was found to be heat-labile and was completely blocked by cinnarizine. Fractionation of the amniotic fluid showing vasopressor activity by gel filtration further substantiated the findings reported above. On the basis of these results it was concluded that the pressor activity of the amniotic fluid was due to the presence of an angiotensin II-like substance. Its concentration was found to be higher in the toxaemic group than in normotensive subjects.     

Liberal vs. conservative vasopressor use to maintain mean arterial blood pressure during resuscitation of septic shock: an observational study

OBJECTIVE: The optimal role of vasopressor therapy in septic shock is not known. We hypothesized that the variability in the use of vasopressors to treat hypotension is associated with subsequent organ failures. DESIGN: Retrospective observational single-center cohort study. SETTING: Tertiary care hospital. PATIENTS AND PARTICIPANTS: Consecutive patients with septic shock. MEASUREMENT AND RESULTS: Ninety-five patients were enrolled. Serial blood pressure recordings and vasopressor use were collected during the first 12h of septic shock. Median duration of hypotension that was not treated with vasopressors was 1.37h (interquartile range [IQR] 0.62-2.66). Based on the observed variability, we evaluated liberal (duration of untreated hypotension < median) vs. conservative (duration of untreated hypotensionn > median) vasopressor therapy. Compared with patients who received conservative vasopressor therapy, patients treated liberally had similar baseline organ impairment [median Sequential Organ Failure Assessment (SOFA) score 8 vs. 8, p = 0.438] were more likely to be younger (median age 70 vs. 77 years, p = 0.049), to require ventilator support (78 vs. 49%, p < 0.001), and to have progression of organ failures after 24h (59 vs. 37%, p = 0.032). When adjusted for age and mechanical ventilation, early therapy aimed at achieving global tissue perfusion [odds ratio (OR) 0.33, 95% confidence interval (CI) 0.11-0.88), and early adequate antibiotic therapy (OR 0.27, 95% CI 0.09-0.76), but not liberal vasopressor use (OR 2.13, 95% CI 0.80-5.84), prevented progression of organ failures. CONCLUSIONS: In our retrospective study, early adequate antibiotics and achieving adequate global perfusion, but not liberal vasopressor therapy, were associated with improved organ failures after septic shock. Clinical trials which compare conservative vs. liberal vasopressor therapy are warranted.     

不同MELD评分患者术前临床特征及MELD评分对肝移植术中循环调控的影响

目的探讨不同MELD评分患者术前的临床特征及MELD评分对终末期肝病病人肝移植手术中循环调控的影响．方法124例2004年1月至12月在加州大学洛杉矶分校医疗中心行肝移植手术病人,根据术前患者MELD评分分为2组,MELD≤30为低MELD评分组,MELD〉30为高MELD评分组,比较两组患者术前临床资料、实验室生化指标和术中输血量及升压药使用情况．结果术前凝血酶原时间国际标准化比值（INR）、血清肌酐、血球压积和纤维蛋白原两组间差异有显著性,高MELD评分组术前气管插管机械通气及使用升压药更常见,术中输血量及升压药使用率明显增加．结论高MELD评分患者术前病情较重,术中有较多的并发症,需更严密的麻醉监测和管理．     

Norepinephrine and hospital mortality in critically ill patients undergoing continuous renal replacement therapy

High-dose vasopressor use is associated with increasing mortality in patients with septic shock. We conducted this study to determine if the high-dose of vasopressor used before the initiation of continuous renal replacement therapy (CRRT) is associated with increasing mortality in critically ill patients. We retrospectively reviewed all patients who underwent CRRT in the medical intensive care unit of China Medical University Hospital between 2003 and 2007. The association between mortality and highest vasopressors (dopamine and norepinephrine [NE]) dose used were analyzed using Kaplan-Meier analysis and multivariate Cox regression. A total of 279 patients (170 men and 109 women) treated with CRRT in medical intensive care were reviewed and 237 (84.9%) died. In Kaplan-Meier analysis with log-rank test, dopamine dose of ≥20 μg/kg/min and NE dose of ≥0.3 μg/kg/min were significantly linked to mortality (P = 0.007 and <0.001). In multivariate Cox proportional hazards regression, NE dose of ≥0.3 μg/kg/min, Acute Physiology and Chronic Health Evaluation II score, and low platelet count were independently linked to mortality. The hazard ratios and 95% confidence interval (CI) were 1.771 (95% CI: 1.247-2.516, P = 0.001), 1.035 (95% CI: 1.012-1.058, P = 0.003), and 0.997 (95% CI: 0.996-0.999, P = 0.003), respectively. Critically ill patients treated with very high dose of NE before the initiation of CRRT have a very high mortality rate regardless of the acute kidney injury stage.     

Characteristics of patients receiving vasopressors

Background

Patients receiving intensive care frequently need pharmacologic support of their blood pressure because of shock. In some patients, shock is so severe that extremely high doses of vasopressors are needed to elevate their blood pressure.

Objective

We sought to ascertain the maximal dose of vasopressors administered to patients, and to describe the population of patients receiving vasopressors in one intensive care unit.

Methods

All adult patients admitted in 2001 to a 10-bed surgical unit in a university hospital, and receiving a vasopressor agent for 1 hour or more, underwent recordings of their demographic data, diagnoses upon admission, Acute Physiological and Chronic Health Evaluation (APACHE) II scores, vasopressors (including type, initial dose, dose increases, and maximal dose), number of days administered, complications, and mortality.

Results

Of 689 patients whose charts were reviewed, 72 received vasopressors. The mean age was 65 ± 21.4 years, and 66% were male. The mean APACHE II scores were 24 ± 6.2. The administration of .5 μg/kg/minute of norepinephrine or epinephrine resulted in 96% sensitivity and a specificity of 76% for the likelihood of mortality. Using Kaplan-Meyer curves, those patients receiving less than .5 μg/kg/minute demonstrated an 80% 6-year survival. All 17 patients receiving more than 3.8 μg/kg/minute of norepinephrine, and all 5 patients receiving more than 9.6 μg/kg/minute of epinephrine, died. The length of time during which patients received less than their maximal dose of vasopressors had no influence on survival (P = .4). The elderly (aged ≥75 years) and the young (aged <75 years) had the same intensive care unit survival rates when receiving vasopressors.

Conclusion

In this study, little likelihood of intensive care unit survival was evident when patients received more than .5 μg/kg/minute of norepinephrine or epinephrine.