Archive for the ‘sepsis’ Category

Esmolol in septic shock

Effect of heart rate control with esmolol on hemodynamic and clinical outcomes in patients with septic shock: a randomized clinical trial.

Morelli A1 et al

JAMA. 2013 Oct 23;310(16):1683-91. doi: 10.1001/jama.2013.278477.

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A Black Water Day ?

Mortality after Fluid Bolus in African Children with Severe Infection. Maitland, K et al. New England Journal of Medicine, May 26th 2011 (epub ahead of print) (DOI: 10.1056/NEJMe1105490)
An interesting paper published in this weeks NEJM will cause substantial comment and concern after it’s headline result showed increased mortality with rapid fluid resuscitation in paediatric sepsis. This surprising result is potentially extremely important as, if verified, undermines much of peadiatric (and adult)emergency care.

Before examining the paper in detail it’s worth making a few comments on what we think we know already….

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SOAP II – That’s cleaned that up then.

Dopamine has been the vasopressor of choice in septic patients in continental europe historically, although this may be changing. Dopamine has theoretically beneficial effects in maintaining splancnic and renal perfusion although in the SOAP trial (observational) suggested that there was an excess of mortality of dopamine treated patients. The old story of “renal dose dopamine” having an additional effect over and above the improvement in perfusing pressure has been discredited, but this result suggests a harmful signal over and above noradrenaline (the preferred agent in the UK).

Comparison of dopamine and norepinephrine in the treatment of shock. De Backer DN, et al. N Engl J Med. 2010 Mar 4;362(9):779-89.
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Special K – time for a reappraisal ?

2 recent articles highlight the potential benefit of an often overlooked induction agent in critically ill patients.

Etomidate versus ketamine for rapid sequence intubation in acutely ill patients: a multicentre randomised controlled trial. Jabre, P. et al. Lancet. Volume 374, Issue 9686, Pages 293 – 300, 25 July 2009.

This multicentre, randomised, blinded trial in 65 french ICUs & 12 field teams enrolled 655 patients to either etomidate or ketamine for emergent intubation for critical illness. Patients were analysed only if they remained in ICU after day 3 (469). Adequate and reasonable power calculation, including predetermined septic & trauma subgroups. Primary end point was maximal SOFA score within 3 days (chosen as etomidate’s effects on adrenocortical axis thought to last <48 hrs). Secondary end points included intubation conditions, and 28 day ICU stay, catecholamine requirement, mortality & adrenocortical insufficiency. Continue reading

Use of Polyclonal Ig as Adjuvant Therapy for Sepsis/Severe Sepsis K Georg. Kreymann et al CCM 2007 35(12) 2677-

This important paper is a meta analysis of all trials including the use of IVIG in patients (adult and Children-including neonates) with sepsis and severe sepsis. IVIG bind up toxins, allow oponisation and bind toxins and superantigens Previous papers from the Cochrane group have apparently not included all studies which this meta analysis has tried to do.
The search criteria was vigorous, including peer reviewed articles as well as personal communications, letters etc. They particularly included studies which used mortality as an end point. They graded papers on strict guidelines as there was a paucity of double blinded randomised placebo controlled trials (DBRPCT) to try and add some power to the meta analysis.

In all 27 trials were included. In 15 trials, including 1492 patients (adults and children) showed the use of IVIG created a RR of 0.79 (significant). When split into type of IVIG, the IVIGAM (immunoglobulins containing predominantly IVIG A and M) were used in 560 patients with a significant RR of 0.66. With just IVIG, including 932 patients, RR was 0.85 (significant). IVIG A and M showed further benefit over just IVIG. It is interesting to note many studies showed a positive trend but these trials were rated as significantly heterogeneous on tests. The largest trial showed no difference between those treated with IVIG and these not. 12 trials included neonates and are not discussed further here.

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