Septic shock treatment remains a major challenge for intensive care units,despite the recent prominent advances in both management and outcomes.Vasopressors serve as a cornerstone of septic shock therapy,but there is ...Septic shock treatment remains a major challenge for intensive care units,despite the recent prominent advances in both management and outcomes.Vasopressors serve as a cornerstone of septic shock therapy,but there is still controversy over the timing of administration.Specifically,it remains unclear whether vasopressors should be used early in the course of treatment.Here,we provide a systematic review of the literature on the timing of vasopressor administration.Research was systematically identified through PubMed,Embase and Cochrane searching according to PRISMA guidelines.Fourteen studies met the eligibility criteria and were included in the review.The pathophysiological basis for early vasopressor use was classified,with the exploration on indications for the early administration of mono-vasopressors or their combination with vasopressin or angiotensinII.We found that mortality was 28.1%-47.7%in the early vasopressors group,and 33.6%-54.5%in the control group.We also investigated the issue of vasopressor responsiveness.Furthermore,we acknowledged the subsequent challenge of administration of high-dose norepinephrine via peripheral veins with early vasopressor use.Based on the literature review,we propose a possible protocol for the early initiation of vasopressors in septic shock resuscitation.展开更多
Vasopressors are routinely used to counteract hypotension after neuraxial anesthesia in Obstetrics. The understanding of the mechanism of hypotension and the choice of vasopressor has evolved over the years to a point...Vasopressors are routinely used to counteract hypotension after neuraxial anesthesia in Obstetrics. The understanding of the mechanism of hypotension and the choice of vasopressor has evolved over the years to a point where phenylephrine has become the preferred vasopressor. Due to the absence of definitive evidence showing absolute clinical benefit of one over the other, especially in emergency and high-risk Cesarean sections, our choice of phenylephrine over the other vasopressors like mephentermine, metaraminol, and ephedrine is guided by indirect evidence on fetalacid-base status. This review article evaluates the present day evidence on the various vasopressors used in obstetric anesthesia today.展开更多
BACKGROUND:Consensus guidelines suggested that both dopamine and norepinephrine may be used,but specific doses are not recommended.The aim of this study is to determine the predictive role of vasopressors in patients ...BACKGROUND:Consensus guidelines suggested that both dopamine and norepinephrine may be used,but specific doses are not recommended.The aim of this study is to determine the predictive role of vasopressors in patients with shock in intensive care unit.METHODS:One hundred and twenty-two patients,who had received vasopressors for 1 hour or more in intensive care unit(ICU) between October 2008 and October 2011,were included.There were 85 men and 37 women,with a median age of 65 years(55-73 years).Their clinical data were retrospectively collected and analyzed.RESULTS:The median simplified acute physiological score 3(SAPS 3) was 50(42-55).Multivariate analysis showed that septic shock(P=0.018,relative risk:4.094;95%confidential interval:1.274-13.156),SAPS 3 score at ICU admission(P=0.028,relative risk:1.079;95%confidential interval:1.008-1.155),and norepinephrine administration(P<0.001,relative risk:9.353;95%confidential interval:2.667-32.807) were independent predictors of ICU death.Receiver operating characteristic curve analysis demonstrated that administration of norepinephrine ≥0.7 μg/kg per minute resulted in a sensitivity of 75.9%and a specificity of 90.3%for the likelihood of ICU death.In patients who received norepinephrine ≥0.7 μg/kg per minute there was more ICU death(71.4%vs.44.8%) and in-hospital death(76.2%vs.48.3%) than in those who received norepinephrine <0.7 ug/kg per minute.These patients had also a decreased 510-day survival rate compared with those who received norepinephrine <0.7 μg/kg per minute(19.2%vs.64.2%).CONCLUSION:Septic shock,SAPS 3 score at ICU admission,and norepinephrine administration were independent predictors of ICU death for patients with shock.Patients who received norepinephrine ≥0.7 μg/kg per minute had an increased ICU mortality,an increased inhospital mortality,and a decreased 510-day survival rate.展开更多
Septic shock impacts approximately 6% of hospitalized patients with cirrhosis and is associated with high rates of morbidity and mortality. Although a number of landmark clinical trials have paved the way for incremen...Septic shock impacts approximately 6% of hospitalized patients with cirrhosis and is associated with high rates of morbidity and mortality. Although a number of landmark clinical trials have paved the way for incremental improvements in the diagnosis and management of septic shock in the general population, patients with cirrhosis have largely been excluded from these studies and critical knowledge gaps continue to impact the care of these individuals. In this review,we discuss nuances in the care of patients with cirrhosis and septic shock using a pathophysiology-based approach. We illustrate that septic shock may be challenging to diagnose in this population in the context of factors such as chronic hypotension, impaired lactate metabolism, and concomitant hepatic encephalopathy. Furthermore, we demonstrate that the application of routine interventions such as intravenous fluids, vasopressors, antibiotics, and steroids should be carefully considered among those with decompensated cirrhosis in light of hemodynamic, metabolic, hormonal, and immunologic disturbances. We propose that future research should include and characterize patients with cirrhosis in a systematic manner, and clinical practice guidelines may need to be refined accordingly.展开更多
Hepatorenal syndrome(HRS) plays an important role in patients with liver cirrhosis on the wait list for liver transplantation(LT). The 1 and 5-year probability of developing HRS in cirrhotic with ascites is 20% and 40...Hepatorenal syndrome(HRS) plays an important role in patients with liver cirrhosis on the wait list for liver transplantation(LT). The 1 and 5-year probability of developing HRS in cirrhotic with ascites is 20% and 40%, respectively. In this article, we reviewed current concepts in HRS pathophysiology, guidelines for HRS diagnosis, effective treatment options presently available, and controversies surrounding liver alone vs simultaneous liver kidney transplant(SLKT) in transplant candidates. Many treatment options including albumin, vasoconstrictors, renal replacement therapy, and eventual LT have remained a mainstay in the treatment of HRS. Unfortunately, even after aggressive measures such as terlipressin use, the rate of recovery is less than 50% of patients. Moreover, current SLKT guidelines include:(1) estimation of glomerular filtration rate of 30 m L/min or less for 4-8 wk;(2) proteinuria > 2 g/d; or(3) biopsy proven interstitial fibrosis or glomerulosclerosis. Even with these updated criteria there is a lack of consistency regarding longterm benefits for SLKT vs LT alone. Finally, in regards to kidney dysfunction in the post-transplant setting, an estimation of glomerular filtration rate < 60 mL /min per 1.73 m2 may be associated with an increased risk of patients having long-term end stage renal disease. HRS is common in patients with cirrhosis and those on liver transplant waitlist. Prompt identification and therapy initiation in transplant candidates with HRS may improve post-transplantation outcomes. Future studies identifying optimal vasoconstrictor regimens, alternative therapies, and factors predictive of response to therapy are needed. The appropriate use of SLKT in patients with HRS remains controversial and requires further evidence by the transplant community.展开更多
Ascorbic acid(vitamin C) elicits pleiotropic effects in thebody. Among its functions, it serves as a potent antioxidant, a co-factor in collagen and catecholamine synthesis, and a modulator of immune cell biology. Fur...Ascorbic acid(vitamin C) elicits pleiotropic effects in thebody. Among its functions, it serves as a potent antioxidant, a co-factor in collagen and catecholamine synthesis, and a modulator of immune cell biology. Furthermore, an increasing body of evidence suggests that highdose vitamin C administration improves hemodynamics, end-organ function, and may improve survival in critically ill patients. This article reviews studies that evaluate vitamin C in pre-clinical models and clinical trials with respect to its therapeutic potential.展开更多
Acute kidney injury（AKI） is a common complication following orthotopic liver transplantation（OLT） and is associated with increased morbidity and mortality. The aim of the current study was to determine the risk fa...Acute kidney injury（AKI） is a common complication following orthotopic liver transplantation（OLT） and is associated with increased morbidity and mortality. The aim of the current study was to determine the risk factors for AKI in patients undergoing OLT. A total of 103 patients who received OLT between January 2015 and May 2016 in Tongji Hospital, China, were retrospectively analyzed. Their demographic characteristics and perioperative parameters were collected, and AKI was diagnosed using 2012 Kidney Disease： Improving Global Outcomes（KDIGO） staging criteria. It was found that the incidence of AKI was 40.8% in this cohort and AKI was significantly associated with body mass index, urine volume, operation duration（especially 〉 480 min）, and the postoperative use of vasopressors. It was concluded that relative low urine output, long operation duration, and the postoperative use of vasopressors are risk factors for AKI following OLT.展开更多
Evaluating and managing circulatory failure is one of the most challenging tasks for medical practitioners involved in critical care medicine.Understanding the applicability of some of the basic but,at the same time,c...Evaluating and managing circulatory failure is one of the most challenging tasks for medical practitioners involved in critical care medicine.Understanding the applicability of some of the basic but,at the same time,complex physiological processes occurring during a state of illness is sometimes neglected and/or presented to the practitioners as point-of-care protocols to follow.Furthermore,managing hemodynamic shock has shown us that the human body is designed to fight to sustain life and that the compensatory mechanisms within organ systems are extraordinary.In this review article,we have created a minimalistic guide to the clinical information relevant when assessing critically ill patients with failing circulation.Measures such as organ blood flow,circulating volume,and hemodynamic biomarkers of shock are described.In addition,we will describe historical scientific events that led to some of our current medical practices and its validation for clinical decision making,and we present clinical advice for patient care and medical training.展开更多
BACKGROUND Sepsis is a severe clinical syndrome related to the host response to infection.The severity of infections is due to an activation cascade that will lead to an auto amplifying cytokine production:The cytokin...BACKGROUND Sepsis is a severe clinical syndrome related to the host response to infection.The severity of infections is due to an activation cascade that will lead to an auto amplifying cytokine production:The cytokine storm.Hemoadsorption by CytoSorb®therapy is a new technology that helps to address the cytokine storm and to regain control over various inflammatory conditions.AIM To evaluate prospectively CytoSorb®therapy used as an adjunctive therapy along with standard of care in septic patients admitted to intensive care unit(ICU).METHODS This was a prospective,real time,investigator initiated,observational multicenter study conducted in patients admitted to the ICU with sepsis and septic shock.The improvement of mean arterial pressure and reduction of vasopressor needs were evaluated as primary outcome.The change in laboratory parameters,sepsis scores[acute physiology and chronic health evaluation(APACHE II)and sequential organ failure assessment(SOFA)]and vital parameters were considered as secondary outcome.The outcomes were also evaluated in the survivor and nonsurvivor group.Descriptive statistics were used;a P value<0.05 was considered RESULTS Overall,45 patients aged≥18 and≤80 years were included;the majority were men(n=31;69.0%),with mean age 47.16±14.11 years.Post CytoSorb®therapy,26 patients survived and 3 patients were lost to follow-up.In the survivor group,the percentage dose reduction in vasopressor was norepinephrine(51.4%),epinephrine(69.4%)and vasopressin(13.9%).A reduction in interleukin-6 levels(52.3%)was observed in the survivor group.Platelet count improved to 30.1%(P=0.2938),and total lung capacity count significantly reduced by 33%(P<0.0001).Serum creatinine and serum lactate were reduced by 33.3%(P=0.0190)and 39.4%(P=0.0120),respectively.The mean APACHE II score was 25.46±2.91 and SOFA scores was 12.90±4.02 before initiation of CytoSorb®therapy,and they were reduced significantly post therapy(APACHE II 20.1±2.47;P<0.0001 and SOFA 9.04±3.00;P=0.0003)in the survivor group.The predicted mortality in our patient population before CytoSorb®therapy was 56.5%,and it was reduced to 48.8%(actual mortality)after CytoSorb®therapy.We reported 75%survival rate in patients given treatment in<24 h of ICU admission and 68%survival rates in patients given treatment within 24-48 h of ICU admission.In the survivor group,the average number of days spent in the ICU was 4.44±1.66 d;while in the nonsurvivor group,the average number of days spent in ICU was 8.5±15.9 d.CytoSorb®therapy was safe and well tolerated with no adverse events reported.CONCLUSION CytoSorb®might be an effective adjuvant therapy in stabilizing sepsis and septic shock patients.However,it is advisable to start the therapy at an early stage(preferably within 24 h after onset of septic shock).展开更多
AIM To examine patient-centered outcomes with vasopressin(AVP) use in patients with cirrhosis with catecholaminerefractory septic shock. METHODS We conducted a single center, retrospective cohort study enrolling adult...AIM To examine patient-centered outcomes with vasopressin(AVP) use in patients with cirrhosis with catecholaminerefractory septic shock. METHODS We conducted a single center, retrospective cohort study enrolling adult patients with cirrhosis treated for catecholamine-resistant septic shock in the intensive care unit(ICU) from March 2011 through December 2013. Other etiologies of shock were excluded. Multivariable regression models were constructed for seven and 28-d mortality comparing AVP as a second-line therapy to a group of all other vasoactive agents. RESULTS Forty-five consecutive patients with cirrhosis were treated for catecholamine-resistant septic shock; 21 received AVP while the remaining 24 received another agent [phenylephrine(10), dopamine(6), norepinephrine(4), dobutamine(2), milrinone(2)]. In general,no significant differences in baseline demographics, etiology of cirrhosis, laboratory values, vital signs or ICU mortality/severity of illness scores were observed with the exception of higher MELD scores in the AVP group(32.4, 95%CI: 28.6-36.2 vs 27.1, 95%CI: 23.6-30.6, P = 0.041). No statistically significant difference was observed in unadjusted 7-d(52.4% AVP vs 58.3% and P = 0.408) or 28-d mortality(81.0% AVP vs 87.5% non-AVP, P = 0.371). Corticosteroid administration was associated with lower 28-d mortality(HR = 0.37, 95%CI: 0.16-0.86, P = 0.021) independent of AVP use. CONCLUSION AVP is similar in terms of patient centered outcomes of seven and 28-d mortality, in comparison to all other vasopressors when used as a second line vasoactive agent in catecholamine resistant septic shock. Large-scale prospective study would help to refine current consensus standards and provide further support to our findings.展开更多
Hyponatremia related to ectopic secretion of cancer cells of arginine vasopressin(AVP)or atrial natriuretic peptide(ANP)is most commonly caused by small cell lung cancer.The ideal treatment would be one that not only ...Hyponatremia related to ectopic secretion of cancer cells of arginine vasopressin(AVP)or atrial natriuretic peptide(ANP)is most commonly caused by small cell lung cancer.The ideal treatment would be one that not only corrects the hyponatremia,especially if it is life threatening,but at the same time causes regression of the cancer,and thus improves both quality and length of life.As one is waiting for chemotherapy,surgery,or radiotherapy to decrease the cancer burden,tolvaptan has been used to correct the hyponatremia to improve symptoms or prevent death.Mifepristone,a progesterone receptor modulator/antagonist has been used to treat various cancers.The oral 200mg tablet was given to an 80-year-old woman who developed sudden extensive lung cancer with a serum sodium of 118 mmol/L.She refused chemotherapy but agreed to take mifepristone.The hyponatremia was completely corrected(145 mmol/L)within one month of treatment.She was in complete remission for 5 years and died not from lung cancer,but an acute myocardial infarction.Mifepristone may serve the purpose to not only quickly correct hyponatremia when it is related to an endocrine paraneoplastic syndrome,but also to provide improved quality and length of life.展开更多
文摘Septic shock treatment remains a major challenge for intensive care units,despite the recent prominent advances in both management and outcomes.Vasopressors serve as a cornerstone of septic shock therapy,but there is still controversy over the timing of administration.Specifically,it remains unclear whether vasopressors should be used early in the course of treatment.Here,we provide a systematic review of the literature on the timing of vasopressor administration.Research was systematically identified through PubMed,Embase and Cochrane searching according to PRISMA guidelines.Fourteen studies met the eligibility criteria and were included in the review.The pathophysiological basis for early vasopressor use was classified,with the exploration on indications for the early administration of mono-vasopressors or their combination with vasopressin or angiotensinII.We found that mortality was 28.1%-47.7%in the early vasopressors group,and 33.6%-54.5%in the control group.We also investigated the issue of vasopressor responsiveness.Furthermore,we acknowledged the subsequent challenge of administration of high-dose norepinephrine via peripheral veins with early vasopressor use.Based on the literature review,we propose a possible protocol for the early initiation of vasopressors in septic shock resuscitation.
文摘Vasopressors are routinely used to counteract hypotension after neuraxial anesthesia in Obstetrics. The understanding of the mechanism of hypotension and the choice of vasopressor has evolved over the years to a point where phenylephrine has become the preferred vasopressor. Due to the absence of definitive evidence showing absolute clinical benefit of one over the other, especially in emergency and high-risk Cesarean sections, our choice of phenylephrine over the other vasopressors like mephentermine, metaraminol, and ephedrine is guided by indirect evidence on fetalacid-base status. This review article evaluates the present day evidence on the various vasopressors used in obstetric anesthesia today.
文摘BACKGROUND:Consensus guidelines suggested that both dopamine and norepinephrine may be used,but specific doses are not recommended.The aim of this study is to determine the predictive role of vasopressors in patients with shock in intensive care unit.METHODS:One hundred and twenty-two patients,who had received vasopressors for 1 hour or more in intensive care unit(ICU) between October 2008 and October 2011,were included.There were 85 men and 37 women,with a median age of 65 years(55-73 years).Their clinical data were retrospectively collected and analyzed.RESULTS:The median simplified acute physiological score 3(SAPS 3) was 50(42-55).Multivariate analysis showed that septic shock(P=0.018,relative risk:4.094;95%confidential interval:1.274-13.156),SAPS 3 score at ICU admission(P=0.028,relative risk:1.079;95%confidential interval:1.008-1.155),and norepinephrine administration(P<0.001,relative risk:9.353;95%confidential interval:2.667-32.807) were independent predictors of ICU death.Receiver operating characteristic curve analysis demonstrated that administration of norepinephrine ≥0.7 μg/kg per minute resulted in a sensitivity of 75.9%and a specificity of 90.3%for the likelihood of ICU death.In patients who received norepinephrine ≥0.7 μg/kg per minute there was more ICU death(71.4%vs.44.8%) and in-hospital death(76.2%vs.48.3%) than in those who received norepinephrine <0.7 ug/kg per minute.These patients had also a decreased 510-day survival rate compared with those who received norepinephrine <0.7 μg/kg per minute(19.2%vs.64.2%).CONCLUSION:Septic shock,SAPS 3 score at ICU admission,and norepinephrine administration were independent predictors of ICU death for patients with shock.Patients who received norepinephrine ≥0.7 μg/kg per minute had an increased ICU mortality,an increased inhospital mortality,and a decreased 510-day survival rate.
文摘Septic shock impacts approximately 6% of hospitalized patients with cirrhosis and is associated with high rates of morbidity and mortality. Although a number of landmark clinical trials have paved the way for incremental improvements in the diagnosis and management of septic shock in the general population, patients with cirrhosis have largely been excluded from these studies and critical knowledge gaps continue to impact the care of these individuals. In this review,we discuss nuances in the care of patients with cirrhosis and septic shock using a pathophysiology-based approach. We illustrate that septic shock may be challenging to diagnose in this population in the context of factors such as chronic hypotension, impaired lactate metabolism, and concomitant hepatic encephalopathy. Furthermore, we demonstrate that the application of routine interventions such as intravenous fluids, vasopressors, antibiotics, and steroids should be carefully considered among those with decompensated cirrhosis in light of hemodynamic, metabolic, hormonal, and immunologic disturbances. We propose that future research should include and characterize patients with cirrhosis in a systematic manner, and clinical practice guidelines may need to be refined accordingly.
文摘Hepatorenal syndrome(HRS) plays an important role in patients with liver cirrhosis on the wait list for liver transplantation(LT). The 1 and 5-year probability of developing HRS in cirrhotic with ascites is 20% and 40%, respectively. In this article, we reviewed current concepts in HRS pathophysiology, guidelines for HRS diagnosis, effective treatment options presently available, and controversies surrounding liver alone vs simultaneous liver kidney transplant(SLKT) in transplant candidates. Many treatment options including albumin, vasoconstrictors, renal replacement therapy, and eventual LT have remained a mainstay in the treatment of HRS. Unfortunately, even after aggressive measures such as terlipressin use, the rate of recovery is less than 50% of patients. Moreover, current SLKT guidelines include:(1) estimation of glomerular filtration rate of 30 m L/min or less for 4-8 wk;(2) proteinuria > 2 g/d; or(3) biopsy proven interstitial fibrosis or glomerulosclerosis. Even with these updated criteria there is a lack of consistency regarding longterm benefits for SLKT vs LT alone. Finally, in regards to kidney dysfunction in the post-transplant setting, an estimation of glomerular filtration rate < 60 mL /min per 1.73 m2 may be associated with an increased risk of patients having long-term end stage renal disease. HRS is common in patients with cirrhosis and those on liver transplant waitlist. Prompt identification and therapy initiation in transplant candidates with HRS may improve post-transplantation outcomes. Future studies identifying optimal vasoconstrictor regimens, alternative therapies, and factors predictive of response to therapy are needed. The appropriate use of SLKT in patients with HRS remains controversial and requires further evidence by the transplant community.
文摘Ascorbic acid(vitamin C) elicits pleiotropic effects in thebody. Among its functions, it serves as a potent antioxidant, a co-factor in collagen and catecholamine synthesis, and a modulator of immune cell biology. Furthermore, an increasing body of evidence suggests that highdose vitamin C administration improves hemodynamics, end-organ function, and may improve survival in critically ill patients. This article reviews studies that evaluate vitamin C in pre-clinical models and clinical trials with respect to its therapeutic potential.
基金supported by the National Natural Science Foundation of China(No.81371251)
文摘Acute kidney injury（AKI） is a common complication following orthotopic liver transplantation（OLT） and is associated with increased morbidity and mortality. The aim of the current study was to determine the risk factors for AKI in patients undergoing OLT. A total of 103 patients who received OLT between January 2015 and May 2016 in Tongji Hospital, China, were retrospectively analyzed. Their demographic characteristics and perioperative parameters were collected, and AKI was diagnosed using 2012 Kidney Disease： Improving Global Outcomes（KDIGO） staging criteria. It was found that the incidence of AKI was 40.8% in this cohort and AKI was significantly associated with body mass index, urine volume, operation duration（especially 〉 480 min）, and the postoperative use of vasopressors. It was concluded that relative low urine output, long operation duration, and the postoperative use of vasopressors are risk factors for AKI following OLT.
文摘Evaluating and managing circulatory failure is one of the most challenging tasks for medical practitioners involved in critical care medicine.Understanding the applicability of some of the basic but,at the same time,complex physiological processes occurring during a state of illness is sometimes neglected and/or presented to the practitioners as point-of-care protocols to follow.Furthermore,managing hemodynamic shock has shown us that the human body is designed to fight to sustain life and that the compensatory mechanisms within organ systems are extraordinary.In this review article,we have created a minimalistic guide to the clinical information relevant when assessing critically ill patients with failing circulation.Measures such as organ blood flow,circulating volume,and hemodynamic biomarkers of shock are described.In addition,we will describe historical scientific events that led to some of our current medical practices and its validation for clinical decision making,and we present clinical advice for patient care and medical training.
文摘BACKGROUND Sepsis is a severe clinical syndrome related to the host response to infection.The severity of infections is due to an activation cascade that will lead to an auto amplifying cytokine production:The cytokine storm.Hemoadsorption by CytoSorb®therapy is a new technology that helps to address the cytokine storm and to regain control over various inflammatory conditions.AIM To evaluate prospectively CytoSorb®therapy used as an adjunctive therapy along with standard of care in septic patients admitted to intensive care unit(ICU).METHODS This was a prospective,real time,investigator initiated,observational multicenter study conducted in patients admitted to the ICU with sepsis and septic shock.The improvement of mean arterial pressure and reduction of vasopressor needs were evaluated as primary outcome.The change in laboratory parameters,sepsis scores[acute physiology and chronic health evaluation(APACHE II)and sequential organ failure assessment(SOFA)]and vital parameters were considered as secondary outcome.The outcomes were also evaluated in the survivor and nonsurvivor group.Descriptive statistics were used;a P value<0.05 was considered RESULTS Overall,45 patients aged≥18 and≤80 years were included;the majority were men(n=31;69.0%),with mean age 47.16±14.11 years.Post CytoSorb®therapy,26 patients survived and 3 patients were lost to follow-up.In the survivor group,the percentage dose reduction in vasopressor was norepinephrine(51.4%),epinephrine(69.4%)and vasopressin(13.9%).A reduction in interleukin-6 levels(52.3%)was observed in the survivor group.Platelet count improved to 30.1%(P=0.2938),and total lung capacity count significantly reduced by 33%(P<0.0001).Serum creatinine and serum lactate were reduced by 33.3%(P=0.0190)and 39.4%(P=0.0120),respectively.The mean APACHE II score was 25.46±2.91 and SOFA scores was 12.90±4.02 before initiation of CytoSorb®therapy,and they were reduced significantly post therapy(APACHE II 20.1±2.47;P<0.0001 and SOFA 9.04±3.00;P=0.0003)in the survivor group.The predicted mortality in our patient population before CytoSorb®therapy was 56.5%,and it was reduced to 48.8%(actual mortality)after CytoSorb®therapy.We reported 75%survival rate in patients given treatment in<24 h of ICU admission and 68%survival rates in patients given treatment within 24-48 h of ICU admission.In the survivor group,the average number of days spent in the ICU was 4.44±1.66 d;while in the nonsurvivor group,the average number of days spent in ICU was 8.5±15.9 d.CytoSorb®therapy was safe and well tolerated with no adverse events reported.CONCLUSION CytoSorb®might be an effective adjuvant therapy in stabilizing sepsis and septic shock patients.However,it is advisable to start the therapy at an early stage(preferably within 24 h after onset of septic shock).
文摘AIM To examine patient-centered outcomes with vasopressin(AVP) use in patients with cirrhosis with catecholaminerefractory septic shock. METHODS We conducted a single center, retrospective cohort study enrolling adult patients with cirrhosis treated for catecholamine-resistant septic shock in the intensive care unit(ICU) from March 2011 through December 2013. Other etiologies of shock were excluded. Multivariable regression models were constructed for seven and 28-d mortality comparing AVP as a second-line therapy to a group of all other vasoactive agents. RESULTS Forty-five consecutive patients with cirrhosis were treated for catecholamine-resistant septic shock; 21 received AVP while the remaining 24 received another agent [phenylephrine(10), dopamine(6), norepinephrine(4), dobutamine(2), milrinone(2)]. In general,no significant differences in baseline demographics, etiology of cirrhosis, laboratory values, vital signs or ICU mortality/severity of illness scores were observed with the exception of higher MELD scores in the AVP group(32.4, 95%CI: 28.6-36.2 vs 27.1, 95%CI: 23.6-30.6, P = 0.041). No statistically significant difference was observed in unadjusted 7-d(52.4% AVP vs 58.3% and P = 0.408) or 28-d mortality(81.0% AVP vs 87.5% non-AVP, P = 0.371). Corticosteroid administration was associated with lower 28-d mortality(HR = 0.37, 95%CI: 0.16-0.86, P = 0.021) independent of AVP use. CONCLUSION AVP is similar in terms of patient centered outcomes of seven and 28-d mortality, in comparison to all other vasopressors when used as a second line vasoactive agent in catecholamine resistant septic shock. Large-scale prospective study would help to refine current consensus standards and provide further support to our findings.
文摘Hyponatremia related to ectopic secretion of cancer cells of arginine vasopressin(AVP)or atrial natriuretic peptide(ANP)is most commonly caused by small cell lung cancer.The ideal treatment would be one that not only corrects the hyponatremia,especially if it is life threatening,but at the same time causes regression of the cancer,and thus improves both quality and length of life.As one is waiting for chemotherapy,surgery,or radiotherapy to decrease the cancer burden,tolvaptan has been used to correct the hyponatremia to improve symptoms or prevent death.Mifepristone,a progesterone receptor modulator/antagonist has been used to treat various cancers.The oral 200mg tablet was given to an 80-year-old woman who developed sudden extensive lung cancer with a serum sodium of 118 mmol/L.She refused chemotherapy but agreed to take mifepristone.The hyponatremia was completely corrected(145 mmol/L)within one month of treatment.She was in complete remission for 5 years and died not from lung cancer,but an acute myocardial infarction.Mifepristone may serve the purpose to not only quickly correct hyponatremia when it is related to an endocrine paraneoplastic syndrome,but also to provide improved quality and length of life.
