Choice of vasopressor in septic shock: does it matter?

Septic shock is a medical emergency that is associated with mortality rates of 40–70%. Prompt recognition and institution of effective therapy is required for optimal outcome. When the shock state persists after adequate fluid resuscitation, vasopressor therapy is required to improve and maintain adequate tissue/organ perfusion in an attempt to improve survival and prevent the development of multiple organ dysfunction and failure. Controversy surrounding the optimum choice of vasopressor strategy to utilize in the management of patients with septic shock continues. A recent randomized study of epinephrine compared to norepinephrine (plus dobutamine when indicated) leads to more questions than answers.     

Best vasopressor for advanced vasodilatory shock: should vasopressin be part of the mix?

Since the publication of the Surviving Sepsis Campaign guidelines, a number of additional and highly relevant studies have been published addressing the issue of vasopressor use during septic shock. While these new results are provocative, none of the studies are definitive. In sum, they suggest that maybe we should not be thinking of one vasopressor versus another in a winner-takes-all sense. Rather, we should be looking for the best balance of vasopressor agents and, further, the choice likely depends on clinical context. Clinical context may drive the choice of adrenergic agonist; for example, norepinephrine may be superior to dopamine when the potential for arrhythmias is of concern. Norepinephrine may be superior to epinephrine if elevated lactate associated with epinephrine use confounds the clinical picture. The Vasopressin and Septic Shock Trial (VASST) identified an effective dose of arginine vasopressin (AVP) when adrenergic agonist doses are low, but higher doses of AVP may be appropriate in the context of very high adrenergic agonist doses. The effect may be a direct beneficial AVP effect or indirect sparing of adrenergic agonist use. The choice to add AVP may also be influenced by the clinical context, including renal function or the concomitant use of corticosteroids. These interim conclusions, in truth, are hypotheses warranting randomized controlled trials adequately powered to test for survival differences in these severely ill patients.     

Effect of ventilator-associated tracheobronchitis on outcome in patients without chronic respiratory failure: a case–control study

Introduction  

Our objective was to determine the effect of ventilator-associated tracheobronchitis (VAT) on outcome in patients without chronic respiratory failure.     

Does body weight impact the efficacy of vasopressin therapy in the management of septic shock?

Background

Vasopressors used for the management of septic shock are often dosed according to body weight. Use of vasopressin for physiologic replacement in patients with septic shock is usually administered as a standard non–weight-based dose. We hypothesized that the efficacy of vasopressin may be influenced by body weight.

Purpose

The primary objective was to determine if the effects of vasopressin on other vasopressor dosing requirements is related to body weight. Secondary objectives included evaluation of blood pressure and heart rate after the start of vasopressin infusion.

Methods

A retrospective, cohort study in a large academic health center was conducted. Sixty-four adult inpatients with septic shock (26 medical intensive care unit and 38 surgical intensive care unit) who required vasopressor administration including vasopressin therapy were included. Dosing requirements of vasopressors were captured 1 hour before and during the hour of vasopressin initiation and 2 and 4 hours later. Other information collected during the study period included blood pressure, mean arterial pressure, and heart rate.

Results

Most of the patients (n = 61) received vasopressin at a dose of 0.04 U/min. Changes in vasopressor dosing were significantly correlated with weight-adjusted vasopressin at 2 hours (correlation coefficient = −0.36, P = .03) and 4 hours (correlation coefficient = −0.46, P < .001). Use of vasopressin was associated with significant increases in systolic blood pressure, diastolic blood pressure, and mean arterial pressure at each time point compared with baseline.

Conclusions

Effects of vasopressin on catecholamine dosing requirements in the setting of septic shock may be influenced by body weight. Prospective studies are needed to examine weight-based dosing of vasopressin in this setting.     

Vaginal bacterial profiles of aerobic vaginitis: a case–control study

PurposeAerobic vaginitis (AV) has drawn increasing attention because of its threat to women's reproductive health and pregnancy. However, little is known about the overall structure of vaginal bacterial communities in women with AV.MethodsThe diversity of vaginal microbiota was evaluated by amplicon sequencing targeting the 16S rRNA V4 region. Routine laboratory tests, including cultivation, were used.ResultsFirmicutes (mainly Lactobacillus crispatus and L. iners) were dominant in healthy women (n = 160), while Actinobacteria and Bacteroidetes were strongly associated with AV (n = 80). The onset of AV was marked by a striking decline in L. crispatus and an increase in multiple aerobes, including Streptococcus agalactiae, S. anginosus, etc. The overall drug resistance level of gram-positive bacteria against erythromycin and clindamycin was high, and the overall drug resistance level of gram-negative bacteria against ampicillin was high.ConclusionsMultiple aerobes and facultative anaerobes were involved in vaginal dysbiosis, which was associated with decreasing L. crispatus levels. Probiotics containing L. crispatus may be potential supplementary agents.     

Dopamine therapy in septic shock: Detrimental effect on survival?

Objective

The aim of this study is to examine the potential impact of dopamine therapy on 28-day mortality in adult septic shock.

Methods

For 66 months, clinical data, medications taken before admission, doses of catecholamines used, and biological parameters were recorded prospectively in all patients admitted for septic shock. This observational study was followed by (1) post hoc multivariate analyses and (2) risk-adjusted matched cohort study.

Measurements and main results

In 277 patients (65 ± 14 years; Simplified Acute Physiology Score II = 54 ± 19, 28-day mortality = 45%; hospital mortality = 53%), 6 factors were linked to 28-day mortality, including Simplified Acute Physiology Score II (P < .0001) and the use of dopamine (P = .043). In a pair-matched cohort of 132 patients, we observed a higher mortality with dopamine (28-day mortality of 62% vs 41%, respectively; P = .006). Dopamine remained linked to day 28 mortality by conditional logistic analysis (odds ratio = 6.2 [1.5-25]). A strong interaction between essential hypertension and dopamine was found, associated to 81% 28-day mortality in patients having both conditions.

Conclusions

In our cohort study, dopamine use was linked to mortality as compared to other vasopressor therapies, particularly in patients with essential hypertension. Future randomized studies attempting to compare dopamine with other therapies in septic shock should pay attention to patients with essential hypertension.     

Patient-reported outcomes for patients undergoing radical cystectomy: a prospective case–control study

Purpose

The purpose of this study was to measure patient-reported outcomes (PROs) for patients with muscle-invasive bladder cancer (BC) before the diagnosis of BC was known, thus before cystectomy, and until 1 year postcystectomy. The differences in outcomes between a health status (HS) and quality of life (QoL) questionnaires were examined.

Methods

From July 2007 to July 2010, 598 patients with primary hematuria were enrolled in this prospective, multi-centre case–control (CC) study. Patients undergoing radical cystectomy (RC; N?=?18) were compared with patients with other causes of hematuria (CC, N?=?20). Measurement points were before diagnosis as well as 3, 6 and 12 months postcystectomy. Questionnaires used were the WHOQOL-BREF, SF-12, International Index of Erectile Function, and 10-item STAI-Trait scale.

Results

Prediagnosis patients who later appeared to have BC had the same QoL compared to CC patients. The prediagnosis physical component scale of HS and sexual function were significantly lower for RC vs. CC patients. RC patients had a better prediagnostic QoL and HS than postcystectomy at all time points.

Conclusions

This is the first case–control study with a baseline measurement of PROs before the diagnosis of BC was known. It shows lower physical health and sexual function for RC vs. CC before diagnosis is known. Until 1 year postcystectomy, QoL does not return to baseline level. Future studies including comorbidity and smoking history are needed to examine the generalizability of our results.     

Improvement of antibiotic therapy and ICU survival in severe non-pneumococcal community-acquired pneumonia: a matched case–control study

IntroductionWe aimed to compare intensive care unit mortality due to non-pneumococcal severe community-acquired pneumonia between the periods 2000–2002 and 2008–2014, and the impact of the improvement in antibiotic strategies on outcomes.MethodsThis was a matched case–control study enrolling 144 patients with non-pneumococcal severe pneumonia: 72 patients from the 2000–2002 database (CAPUCI I group) were paired with 72 from the 2008–2014 period (CAPUCI II group), matched by the following variables: microorganism, shock at admission, invasive mechanical ventilation, immunocompromise, chronic obstructive pulmonary disease, and age over 65 years.ResultsThe most frequent microorganism was methicillin-susceptible Staphylococcus aureus (22.1 %) followed by Legionella pneumophila and Haemophilus influenzae (each 20.7 %); prevalence of shock was 59.7 %, while 73.6 % of patients needed invasive mechanical ventilation. Intensive care unit mortality was significantly lower in the CAPUCI II group (34.7 % versus 16.7 %; odds ratio (OR) 0.78, 95 % confidence interval (CI) 0.64–0.95; p = 0.02). Appropriate therapy according to microorganism was 91.5 % in CAPUCI I and 92.7 % in CAPUCI II, while combined therapy and early antibiotic treatment were significantly higher in CAPUCI II (76.4 versus 90.3 % and 37.5 versus 63.9 %; p < 0.05). In the multivariate analysis, combined antibiotic therapy (OR 0.23, 95 % CI 0.07–0.74) and early antibiotic treatment (OR 0.07, 95 % CI 0.02–0.22) were independently associated with decreased intensive care unit mortality.ConclusionsIn non-pneumococcal severe community-acquired pneumonia , early antibiotic administration and use of combined antibiotic therapy were both associated with increased intensive care unit survival during the study period.     

Brain lesions in septic shock: a magnetic resonance imaging study

Background Understanding of sepsis-induced brain dysfunction remains poor, and relies mainly on data from animals or post-mortem studies in patients. The current study provided findings from magnetic resonance imaging of the brain in septic shock. Methods Nine patients with septic shock and brain dysfunction [7 women, median age 63 years (interquartile range 61–79 years), SAPS II: 48 (44–56), SOFA: 8 (6–10)] underwent brain magnetic resonance imaging including gradient echo T1-weighted, fluid-attenuated inversion recovery (FLAIR), T2-weighted and diffusion isotropic images, and mapping of apparent diffusion coefficient. Results Brain imaging was normal in two patients, showed multiple ischaemic strokes in two patients, and in the remaining patients showed white matter lesions at the level of the centrum semiovale, predominating around Virchow–Robin spaces, ranging from small multiple areas to diffuse lesions, and characterised by hyperintensity on FLAIR images. The main lesions were also characterised by reduced signal on diffusion isotropic images and increased apparent diffusion coefficient. The lesions of the white matter worsened with increasing duration of shock and were correlated with Glasgow Outcome Score. Conclusion This preliminary study showed that sepsis-induced brain lesions can be documented by magnetic resonance imaging. These lesions predominated in the white matter, suggesting increasedblood–brain barrier permeability, and were associated with poor outcome.     

Efficacy of venlafaxine for the relief of taxane and oxaliplatin-induced acute neurotoxicity: a single-center retrospective case–control study

Background

Oxaliplatin and taxane-induced neurosensory toxicity is dose-limiting and mostly presents with acute symptoms that affect the activities of daily living and overall quality of life. The objective of the present study is to assess the relief of acute neuropathy with venlafaxine treatment during the chemotherapy period.

Patients and methods

In this retrospective case–control study, from January 2010 to February 2015, patients who experienced treatment with oxaliplatin and taxane-induced acute neurotoxicity were evaluated according to the NCI-CTCAE v. 4.03 grading scale. Neurotoxicity was evaluated using a numeric rating scale (NRS) for pain intensity and experienced relief under the treatment of venlafaxine and using a neuropathic pain symptom inventory scale (NPSI) for the style of complaints. Patients who were diagnosed as mildly depressed according to the HOST anxiety and depression scale and who had grade 1 to 3 sensory neurotoxicity based on the NCI-CTCAE v. 4.03 grading scale, and who also reported ≥4/10 on a NRS were eligible. The primary end point was the rate of more than 75 % symptomatic relief under venlafaxine treatment.

Results

Two hundred six patients were included (82 % female, median age: 52.7 years). Most patients had breast, gynecologic, and colon cancer (93.4 %). Ninety-one patients who received venlafaxine and 115 patients as the control group were assessed for neurotoxicity every 3 weeks. Based on the NRS, a rate of more than 75 % symptomatic relief was 53.5, 58.3, and45.2 % in venlafaxine arm versus 0, 0, and 0 % in the control arm in the first, second, and third visits, respectively. Side-effects of venlafaxine (n?=?7) were grade 1–2 nausea/vomiting (3.2 %) and asthenia/somnolence (3.2 %) without grade 3–4 events.

Conclusion

Venlafaxine has a significant clinical activity against taxane-oxaliplatin-induced acute neurosensory toxicity.

     

Effect of platelet–lymphocyte ratio and lactate levels obtained on mortality with sepsis and septic shock

Background

Sepsis is a potentially fatal condition with high treatment costs, and is especially common among the elderly population. The emergency management of septic patients has gained importance.