Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Journal Reading
Gina Ariani
Research Article
Background
Septic shock is a very common condition and
associated with a high mortality rate of 20 %
to 50 % in intensive care unit.
Important interventions for reducing sepsis
mortality
include
aggressive
fluid
resuscitation, early goal-directed therapy, and
early
administration
of
appropriate
antibiotics.
Research Article
Background
Vasopressors are often requires for severe
sepsis that does not respond to fluid
resuscitation.
Norepinephrine (NE), dopamine (DOP),
epinephrine (EPI), low-dose vasopressin
(LDVP), and phenylephrine (PHE) are most
commonly used vasopressor agents for
septic shock.
Research Article
Background
The current evidence-based guidelines
recommend NE as the first choice of
vasopressor (grade 1B).
EPI in addition to or possible substitution
for NE when necessary (grade 2B).
LDVP in addition to NE to decrease NE
dosage (ungraded), and
DOP in place of NE only in highly
selected patients (2C)
Research Article
Background
Current guideline s recommend a trial of DOB in
case of myocardial dysfunction or tissue
hypoperfusion (grade 1C).
The purpose of this study was to systematically
review the overall evidence on vasopressors and
inotropes in septic shock from randomized controlled
trials with a Bayesian network meta-analysis.
Research Article
Research Article
14 studies included in
quantitative
synthesis
(mixed-treatment
comparisons
and
meta
analyses)
(Table 1)
Excluded
: (n
Wrong outcome
Duration too short
Wrong population
Wrong design : 1
= 10)
:2
:5
:2
Research Article
Association between vasopressor and
mortality
28-day or nearest estimate mortality rates
with DOP as a referent treatment.
Norepinephrine and NE + LDVP but not
EPI significantly reduced mortality
compared with DOP in the network
analysis.
Research Article
Association between intropes and
mortality
The addition of DOB did not significantly
affect mortality compared with EPI or NE
alone in the network analysis.
The results were similiar when
dopexamine (DOPE) was added to NE
compared with EPI or NE alone.
.
Research Article
Discussion
With the current guidelines that NE is the first
choice vasopressor in septic shock.
It is reasonable ( and a coomon practice) to add
LDVP rather than EPI or DOP if NE alone does not
provide satisfactory hemodynamic support given
potential survival benefit as demonstrated in this
analysis.
Research Article
Discussion
No concrete data exist to recommend either EPI or
DOP if above measure fail to achieve target blood
pressure.
The choice for an additional agent, when needed,
may be based on side effect profile (ie, DOP for
patients with low risk for tachyarrhtymia and
ventricular arrhythmia or EPI for patients with low
risk for splanchnic ischemia.
Research Article
Discussion
Phenylephrine is recommended when combine
inotrope / vasopressor agents do not achieve target
blood pressure, and cardiac output is known to be
high (grade 1C).
Phenylephrine may be used as salvage therapy
when others measures fail to achieve hemodynamic
goals or tachyarrhythmias limit therapy, whereas
keeping the lack of evidence in mind.
Research Article
Discussion
Dobutamine infusion is an element of this
strategy for patients with low mixed venous
oxygen
saturation
despite
volume
resuscitation
and
vasopressor
administration, but its contribution to
observed improved outcomes with the use
of these bundles is unclear.
Research Article
Conclusion
Our bayesian network meta-analysis support
the use of NE with or without LDVP as the first
line vasopressor therapy in septic shock.
No concrete evidence exist to choose EPI over
DOP as the second line agent.
There is no evidence that the use of an
inotropic agent would improve survival in
septic patients in the presence or absence of
myocardial dysfunction.
Comparison
phenylephrine (PHE).
Norepinephrine (NE), dopamine
(DOP), epinephrine (EPI), lowdose vasopressin (LDVP), and
Outcome
phenylephrine (PHE).
using of NE with or
LDVP
as
the
first
without
line
ICAL APPRAISAL
S THIS REVIEW ADDRESS A CLEAR QUESTION?
1. Did the review address a clearly
focused issue?
Yes
Cant
No
tell
2.
Did
the
authors
look
for
the
Do
you
think
the
Look for
published studies
Search for non English language
studies
t
tell
No
Can
t tell
No
Consider whether
Consider
Yes
Thank You