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Signa Vitae

A Journal In Intensive Care And Emergency Medicine

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Inotropes and vasopressors


Inotropic agents are used to increase myocardial contraction while vasopressors are used to increase vascular tone. They are often used for treatment of patients whose tissue perfusion is insufficient to meet metabolic requirements. Therefore, these agents are usually administered in intensive care units where continuous and invasive monitoring of cardiac function can be applied.

Inotropic agents can be divided into those that increase cAMP levels and those that do not. Adrenergic receptor agonists and phosphodiesterase inhibitors (PDEi) increase cAMP levels and are currently the mainstay of positive inotropic therapy. Levosimendan acts as calcium sensitizer and increases myocardial contraction force without increasing intracellular calcium levels. In addition to existing inotropic agents, new promising inotropes are being developed. These include sarcoplasmic reticulum calcium pump (istaroxime), cardiac myosin activators (omecamtivmecarbil), gene therapy, nitroxyl donors and ryanodine receptor stabilizers.

Current treatments of heart failure are aimed at prolonging survival and not just alleviating symptoms. This review provides a short description of the physiology of myocardial contraction and adrenergic receptors. We also provide a short description of commonly used inotropic agents and vasopressor drugs as well as a short review of agents that are expected are in use in the future.

Inotropes are agents used to increase myocardial contractility, while vasopressors are administered to increase vascular tone(1).Their use ismostly confined to critically ill patients whose hemodynamic impairment is such that tissue perfusion is insufficient to meet metabolic requirements(2). Patients in need of inotropic or vasopressor support are often presented with septic or cardiogenic shock and severe heart failure, and are victims of major trauma or undergoing major surgery.These drugs are therefore administered usually to patients treated in intensive care settings where continuous monitoring of cardiac rhythm, arterial oxygenation, urine output and other invasive hemodynamic monitoring can be applied.Inotropic and vasopressor drugs should be administered through a central venous catheter via infusion pumps that can deliver precise flow rates. These agents are mostly short acting with rapid onset and offset of action. Therefore, they can be used without an initial bolus and can be titrated frequently. Abrupt discontinuation should be avoided because of possible hypotension.

Key words: Inotropes, Vasopressor Agents, Intensive Care, Heart Failure

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Current concepts in fluid therapy and non-invasive haemodynamic monitoring


Advantages of goal directed therapy (GDT) have recently become more and more difficult to prove in the face of newly implemented protocolised patient care approaches that also clearly improve patient outcome. However, individualised approach using GDT has been suggested to be superior to protocolised care and large meta-analyses still consistently show beneficial effects of GDT. Concerns of invasiveness were the reason why some patients’ haemodynamics was not measured and in turn were not included in any GDT protocols. Recently, non-invasive devices to measure arterial blood pressure and haemodynamic variables emerged, and although they are very appealing and easy to use, they require further validation both by comparison to more invasive methods and by outcome trials.

Keywords: Haemodynamic monitoring, non-invasive haemodynamic monitoring, goal-directed therapy, fluid therapy, validation

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CVP vs. dynamic hemodynamic parameters as preload indicators in hemodynamically unstable patients after major surgery


Introduction. Adequate circulating blood volume is essential for the good outcome in postoperative patients. Therefore, the primary resuscitation question is how to assess the circulating volume. The aim of this study was to compare the central venous pressure (CVP) and dynamic LIDCO parameters as markers indicating preload in surgical patients.

Materials and Methods. This prospective study included 24 patients hospitalized after major surgery at the surgical intensive care unit of the University hospital Zagreb, Croatia. The patients were mechanically ventilated, without spontaneous breathing attempts and in sinus rhythm. Patients were divided into 2 groups, hemodynamically stable and hemodynamically unstable. The CVP was measured as a static parameter while the stroke volume variation (SVV) and pulse pressure variation (PPV) were measured as the dynamic parameters.

Results. Study groups were comparable in terms of gender, age and body mass index. The difference in the CVP between the hemodynamically stable (13,2±3,74 mmHg) and hemodynamically unstable group of patients (10,1±5,6 mmHg) was statistically insignificant (p=0,144). Differences in SVV (10,2±6,48% in stable compared to 18,8±7,04% in unstable group) and PPV (11,5±6,65% in stable compared to 18±6,32% in unstable group) were both statistically significant with p values of 0,005 and 0,022 respectively.

Conclusion. The study confirmed the inability of CVP to provide valid assessment of the preload as a reason for hemodynamic instability in comparison to dynamic LiDCOTMplus system parameters in mechanically ventilated major surgical patients.

Key Words: Blood Volume, Central Venous Pressure, Stroke Volume, Pulse Pressure

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Current practice of hemodynamic monitoring with PiCCO in a single general surgical ICU in a university hospital – a short report


Background: In recent years, there has been an overall trend toward using less invasive hemodynamic monitoring in surgical intensive care units. The pulse contour cardiac output monitor (PiCCO) is one of them.

Objectives: The aim of this study was to evaluate our practice of hemodynamic monitoring with PiCCO in the perioperative period.

Methods: A retrospective descriptive analysis was performed in a single general surgical intensive care unit (ICU) run by anesthesiologists for the years 2013-2016. We collected information about patients, ICU quality parameters and monitoring equipment available in the ICU. The primary endpoint was the incidence of PiCCO use.

Results: Out of 2972 patients admitted to the general surgical ICU in a 4-year period, besides basic monitoring with electrocardiography (ECG), pulse oximetry and blood pressure monitoring, more than half of the patients received central venous catheterization (55.1%), less than the half invasive arterial catheterization (44.1 %) and only a small proportion PiCCO (0.91%). No patient received a pulmonary arterial catheter. Mortality rate was 7.47 %.

Conclusion: The use of PiCCO in our ICU is far below reported in literature. In the majority of cases, our anesthesiologists make clinical decisions based on measurement of central venous and invasive arterial pressure.

Key words: hemodynamic monitoring, intensive care unit, general surgery

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Clinical application of lung ultrasound in emergency department patients for the evaluation of pulmonary congestion: a comparison with chest X-ray


Introduction. Lung ultrasound can effectively rule out pulmonary edema when there is an absence of multiple B-lines and enables emergency physicians to improve their diagnostic performance, optimize therapeutic strategy, help early diagnosis for the patient and reduced hospital stay. The primary endpoint of this pilot study was to evaluate the effectiveness of lung ultrasound for diagnosing acute heart failure, even when used by emergency medicine residents, and assess the accuracy of B-line lung ultrasound in comparison to chest X-ray in emergency department patients.

Materials and methods. We enrolled 18 patients consecutively as they arrived at the Emergency Department of Clinical Hospital „Sveti Duh“, Croatia, presenting with undifferentiated acute dyspnea. Positive ultrasound confirmation of acute heart failure was defined as the bilateral existence of 2 or more positive regions with 3 or more B-lines.

Results. We found positive results regarding B-lines profile in 6 patients and cardiac decompensation was confirmed by their chest x-ray findings. The remaining 12 patients did not have B-lines by the LUS examination, neither signs of pulmonary congestion by their chest x-ray examination.

Conclusion. Lung ultrasound, given its practicability, simplicity and reproducibility, used by non-experts in emergency ultrasound, is a reliable tool for clinical examination of patients with acute heart failure.

Key words: emergency department, ultrasonography, heart failure, extravascular lung water

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