Best practice & research. Clinical anaesthesiology
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Best Pract Res Clin Anaesthesiol · Jun 2008
Review"Terlipressin in the treatment of septic shock: the earlier the better"?
Terlipressin, a long-acting vasopressinergic V1 agonist, is increasingly used to increase mean arterial blood pressure in the common setting of catecholamine-refractory septic shock. Traditionally, terlipressin has been used as drug of last resort and administered as intermittent high-dose bolus infusion (1-2 mg every 4 to 6 hours). ⋯ Small-scale clinical studies suggest that low-dose terlipressin, when given as a first-line vasopressor agent, is safe. Randomised, clinical multicenter trials are now needed to investigate whether or not early institution of low-dose continuous terlipressin infusion improves overall outcome of patients suffering from vasodilatory shock states.
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Best Pract Res Clin Anaesthesiol · Jun 2008
ReviewVasopressin analogues in the treatment of shock states: potential pitfalls.
Vasopressin analogues are increasingly used for haemodynamic support of catecholamine-refractory, hyperdynamic septic shock. Arginine vasopressin (AVP) and terlipressin (TP) effectively increase mean arterial pressure and reduce catecholamine requirements in this condition. However, the use of either of the drugs may be linked to relevant haemodynamic side effects, including reductions in cardiac output, oxygen delivery and mixed-venous oxygen saturation. ⋯ Maximum doses of 0.03 (-0.067) U min(-1) of AVP or 2 microg kg(-1) h(-1) of TP, respectively, should not be exceeded. Aggressive fluid therapy may prevent adverse haemodynamic effects linked to infusion of either AVP or TP. Finally, platelet count, surrogate variables of hepatic dysfunction, electrolytes and osmolality should be strictly monitored in patients treated with vasopressin analogues.
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Best Pract Res Clin Anaesthesiol · Jun 2008
ReviewArginine vasopressin vs. terlipressin in the treatment of shock states.
The synthetic vasopressin analogue, terlipressin, is being increasingly used to treat catecholamine-resistant hypotension in septic shock and other conditions. While terlipressin holds some theoretical and anecdotal advantages over vasopressin, this has not been formally tested in prospective randomised trials. This review analyses the published literature and makes comparisons, where possible, between vasopressin and terlipressin.
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Best Pract Res Clin Anaesthesiol · Mar 2008
ReviewGlycaemic control and perioperative organ protection.
The concept of stress hyperglycaemia as an adaptive, beneficial response in critical illness has recently been challenged. Two large prospective randomized controlled trials in the Leuven University Hospital surgical and medical ICUs demonstrated that maintenance of normoglycaemia with intensive insulin therapy substantially prevents morbidity and reduces mortality. Strict normoglycaemia is required to gain most clinical benefit. ⋯ Other studies have been used to advocate against implementation of intensive insulin therapy by showing lack of benefit or questioning safety. However, these studies are inconclusive on this subject, due to problems of not reaching normal glucose levels clearly separated from the standard glycaemic group or lack of statistical power. Clearly, future studies should be adequately powered and comply with the study protocol in order to confirm the survival and other clinical benefits of intensive insulin therapy.
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Perioperative cardiac complications pose the greatest risk to the estimated 100 million people undergoing non-cardiac surgery each year. Most of these complications are related to underlying pre-existing coronary artery disease (CAD). For over 40 years researchers have been studying perioperative cardiac risk and how best to estimate it. ⋯ Risk stratification has taken on an important role in clinical decision-making, helping physicians decide in which patients additional medical therapies, such as coronary revascularization or perioperative beta-blockers, are necessary. Meta-analysis has found a significant improvement in the positive predictive value (PPV) for perioperative cardiac outcome with stress testing over that with clinical risk score alone. However, evidence is mounting that with the use of perioperative beta-blockers, the majority of intermediate and high-risk patients can safely undergo even major vascular surgery without further cardiac testing.