Publications

In patients with septic shock, dopamine administration is associated with greater mortality and a higher incidence of arrhythmic events compared to norepinephrine administration.

Cavicchi, Federica Zama; Pozzebon, Selene; Bond, Ottavia; Scolletta, Sabino; Franchi, Federico; Creteur, Jacques; Vincent, Jean-Louis; Taccone, Fabio Silvio

Brain hypoxia can occur after non-traumatic subarachnoid hemorrhage (SAH), even when levels of intracranial pressure (ICP) remain normal. Brain tissue oxygenation (PbtO₂) can be measured as a part of a neurological multimodal neuromonitoring. Low PbtO₂ has been associated with poor neurologic recovery. There is scarce data on the impact of PbtO₂ guided-therapy on patients' outcome. This single-center cohort study (June 2014-March 2020) included all patients admitted to the ICU after SAH who required multimodal monitoring. Patients with imminent brain death were excluded. Our primary goal was to assess the impact of PbtO₂-guided therapy on neurological outcome. Secondary outcome included the association of brain hypoxia with outcome. Of the 163 patients that underwent ICP monitoring, 62 were monitored with PbtO₂ and 54 (87%) had at least one episode of brain hypoxia. In patients that required treatment based on neuromonitoring strategies, PbtO₂-guided therapy (OR 0.33 [CI 95% 0.12-0.89]) compared to ICP-guided therapy had a protective effect on neurological outcome at 6 months. In this cohort of SAH patients, PbtO₂-guided therapy might be associated with improved long-term neurological outcome, only when compared to ICP-guided therapy.

Introduction: Early prognostication of neurological outcome after cardiopulmonary resuscitation (CPR) is extremely important as it can help to reassess therapeutic intensity or select high-risk patients for specific interventions Hypothesis: Age and biological variables obtained from initial simple blood tests could predict poor neurological outcome (PNO) after CPR Methods: Data from all patients admitted after CPR (in and out-of-hospital) from January 2008 to December 2011 in a mixed 35-bed ICU were assessed. Therapeutic hypothermia was used in all patients. We identified those who had a complete blood gas/electrolyte panel within the first hour after ICU admission. PNO was defined as a cerebral performance category (CPC) score of 4-5 at hospital discharge. We calculated areas under the receiver operating characteristic curve (AUROC) for each variable and derived the score from those having the highest AUROCs. We identified the best cut-off point (the best combination of sensitivity and specificity) which was used as a dichotomic value (0 or 1), with 1 representing PNO. We constructed 20 different models with combinations of the variables to identify the best model according to the highest AUROC. All analyses were performed with SPSS 19.0 Results: A total of 127 patients (mean age 61 years, male gender 76%) were included in the analysis; 69% had out-of-hospital CPR and 57% had shockable rhythms. Overall mortality was 58%. Individual AUROCs (CI 95%) used in the model were: Hemoglobin (Hb) 0.65 (0.55-0.74), blood glucose (Gly) 0.63 (0.53-0.73), lactate (Lac) 0.62 (0.52-0.72), total CO2 (TCO2) 0.59 (0.49-0.69), and age 0.62 (0.52-0.71). The model with the best AUROC (0.772 (0.69-0.85)) included Hb < 12.5 g/dl, Gly > 180 mg/dl, Lac > 2 mEq/L, TCO2 < 20 mEq/L and age? 60 years. Scores of 0-1, 2-3, and 4-5 resulted in predicted PNOs of 30% (7/23), 51% (30/58) and 91% (42/46), and in predicted good neurological outcomes of 69% (16/23), 48% (28/58) and 8% (4/46), respectively. A score of 4-5 had a sensitivity of 53%, specificity of 92%, positive likelihood ratio (LR) of 6.38 and negative LR of 0.51 to predict PNO Conclusions: This simple admission score could help to identify early those patients with likely PNO after CPR

Objective In 2003, critical care and infectious disease experts representing 11 international organizations developed management guidelines for severe sepsis and septic shock that would be of practical use for the bedside clinician, under the auspices of the Surviving Sepsis Campaign, an international effort to increase awareness and improve outcome in severe sepsis. Design The process included a modified Delphi method, a consensus conference, several subsequent smaller meetings of subgroups and key individuals, teleconferences, and electronic-based discussion among subgroups and among the entire committee. Methods We used a modified Delphi methodology for grading recommendations, built on a 2001 publication sponsored by the International Sepsis Forum. We undertook a systematic review of the literature graded along five levels to create recommendation grades from A to E, with A being the highest grade. Pediatric considerations were provided to contrast adult and pediatric management. Results Key recommendations, listed by category and not by hierarchy, include early goal-directed resuscitation of the septic patient during the first 6 hrs after recognition; appropriate diagnostic studies to ascertain causative organisms before starting antibiotics; early administration of broad-spectrum antibiotic therapy; reassessment of antibiotic therapy with microbiology and clinical data to narrow coverage, when appropriate; a usual 7–10 days of antibiotic therapy guided by clinical response; source control with attention to the method that balances risks and benefits; equivalence of crystalloid and colloid resuscitation; aggressive fluid challenge to restore mean circulating filling pressure; vasopressor preference for norepinephrine and dopamine; cautious use of vasopressin pending further studies; avoiding low-dose dopamine administration for renal protection; consideration of dobutamine inotropic therapy in some clinical situations; avoidance of supranormal oxygen delivery as a goal of therapy; stress-dose steroid therapy for septic shock; use of recombinant activated protein C in patients with severe sepsis and high risk for death; with resolution of tissue hypoperfusion and in the absence of coronary artery disease or acute hemorrhage, targeting a hemoglobin of 7–9 g/dL; appropriate use of fresh frozen plasma and platelets; a low tidal volume and limitation of inspiratory plateau pressure strategy for acute lung injury and acute respiratory distress syndrome; application of a minimal amount of positive end-expiratory pressure in acute lung injury/acute respiratory distress syndrome; a semirecumbent bed position unless contraindicated; protocols for weaning and sedation/analgesia, using either intermittent bolus sedation or continuous infusion sedation with daily interruptions/lightening; avoidance of neuromuscular blockers, if at all possible; maintenance of blood glucose <150 mg/dL after initial stabilization; equivalence of continuous veno-veno hemofiltration and intermittent hemodialysis; lack of utility of bicarbonate use for pH ≥7.15; use of deep vein thrombosis/stress ulcer prophylaxis; and consideration of limitation of support where appropriate. Pediatric considerations included a more likely need for intubation due to low functional residual capacity; more difficult intravenous access; fluid resuscitation based on weight with 40–60 mL/kg or higher needed; decreased cardiac output and increased systemic vascular resistance as the most common hemodynamic profile; greater use of physical examination therapeutic end points; unsettled issue of high-dose steroids for therapy of septic shock; and greater risk of hypoglycemia with aggressive glucose control. Conclusion Evidence-based recommendations can be made regarding many aspects of the acute management of sepsis and septic shock that are hoped to translate into improved outcomes for the critically ill patient. The impact of these guidelines will be formally tested and guidelines updated annually and even more rapidly as some important new knowledge becomes available.