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Treatment of the acute respiratory distress syndrome includes both supportive measures and correction of the underlying cause. Various pharmacological interventions have been proposed to limit the severity of lung injury and enhance the healing process, including exogenous surfactant, inhaled vasodilators (mainly nitric oxide), corticosteroids, prostaglandin E1, antioxidants (N-acetylcysteine), ketoconazole and other substances. Some of these interventions are administered via the airways, for example inhaled nitric oxide or liquid ventilation with perfluorocarbons. Some have beneficial effects on surrogate end-points such as pulmonary gas exchange. However, in large prospective trials none of these pharmacological approaches have resulted in significantly improved survival in acute respiratory distress syndrome patients.
The present study explored the possibility of using a short-term dobutamine infusion to disclose oxygen uptake/supply dependency. The effects of a standard dose of 5 µg/kg/min of dobutamine on oxygen-derived variables were studied in 73 acutely ill patients with heart failure (n = 24) or sepsis ( n = 49). In each group, patients were separated according to their blood lactate concentrations (either above or below 2 mEq/L). In all patient groups, dobutamine resulted in significant increases in cardiac output and oxygen transport. However, oxygen consumption increased significantly only in patients with elevated blood lactate levels (cardiac failure: from 108 ± 26 to 131 ± 25 ml/min/M2, n = 8, p < 0.01; sepsis: from 139 ± 44 to 167 ± 68 ml/min/M2, n = 16, p < 0.01) and not in the other patients (heart failure: from 121 ± 29 to 115 ± 31 ml/min/M2, n = 28, NS; sepsis: from 158 ± 39 to 166 ± 45 ml/min/M2, n = 21, NS). These data, therefore, indicate that dobutamine at the dose used does not increase oxygen consumption in critically ill patients unless there is coexistent tissue hypoxia reflected by increased blood lactate levels. A short-term dobutamine infusion can be used to disclose an oxygen uptake/supply dependency phenomenon.
A novel assay for endotoxin, based on the ability of antigen-antibody complexes to prime neutrophils for an augmented respiratory burst response, was studied in a cohort study of 857 patients admitted to an intensive-care unit (ICU). On the day of ICU admission, 57.2% of patients had either intermediate (>or=0.40 endotoxin activity [EA] units) or high (>or=0.60 units) EA levels. Gram-negative infection was present in 1.4% of patients with low EA levels, 4.9% with intermediate levels, and 6.9% with high levels; EA had a sensitivity of 85.3% and a specificity of 44.0% for the diagnosis of gram-negative infection. Rates of severe sepsis were 4.9%, 9.2%, and 13.2%, and ICU mortality was 10.9%, 13.2%, and 16.8% for patients with low, intermediate, and high EA levels, respectively. Stepwise logistic regression analysis showed that elevated Acute Physiology and Chronic Health Evaluation II score, gram-negative infection, and emergency admission status were independent predictors of EA.
Polymerase chain reaction/electrospray ionization-mass spectrometry provides rapid pathogen identification in critically ill patients. The ability to rule out infection within 6 hours has potential clinical and economic benefits.
Splanchnic ischemia may be involved in the development of multiple organ failure. Vasoactive agents may influence not only splanchnic blood flow but also the distribution of blood flow within the gut and the balance between oxygen supply and demand in the splanchnic area. This article focuses on the effects of pharmacologic agents including adrenergic agents, prostacyclin, nitric oxide donors or inhibitors, and hemoglobin solutions on splanchnic blood flow.
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(Abstracted from Anesthesiology, 126(1):85–93, 2017) The purpose of this prospective, double-blind, randomized controlled trial was to gauge whether vasopressin is superior to norepinephrine in reducing postoperative complications in patients with vasoplegic syndrome. This complication, which presents in 5% to 25% of cardiac surgery patients, is characterized by low arterial pressure with either normal or elevated cardiac output but reduced systemic vascular resistance.
