North American Survey of Vasopressor and Inotrope Use in Severe Sepsis and Septic Shock

Objective: The primary objective of this study was to characterize how vasopressor and inotropic agents are prescribed and administered in the hemodynamic management of sepsis. Secondary objectives were 1) to evaluate adherence with published guidelines to identify areas of deviation and 2) to describe pharmacists’ perceived incidence of adverse drug reactions (ADRs) of vasopressors and inotropes.
Design and setting: Web-based survey.
Patients and participants: Critical care pharmacists.
Interventions: An email invitation was sent to critical care pharmacists asking them to complete a web-based survey. The survey opened September 29, 2004 and closed March 4, 2005.
Measurements and results: Of 1065 pharmacists, 235 (22.1%) responded to the survey. Median hospital and ICU size were 451 and 20 beds, respectively. Primary types of ICUs included general (42.1%), medical (28.5%), surgical/trauma (18.3%), cardiac (9.8%), and other (1.3%). Independent of pulmonary artery catheter (PAC) use, the most common initial vasopressor choice in surgical/trauma ICUs was norepinephrine. In the other ICUs, the most common first-line agent was norepinephrine if a PAC was present and dopamine if a PAC was not present. The most common dosage regimen of vasopressin was a continuous infusion of 0.04 units/min (49.8%). The most commonly used inotrope was dobutamine. Respondents reported using inotropes either sometimes (48.1%) or rarely (34.0%), with therapy continuing 24–48 (54.5%) or 48–72 (26.0%) hours. Commonly associated agents with specifi c adverse effects included dopamine with tachycardia and norepinephrine with digital ischemia. Much variability was shown in drug concentrations and various dosages of vasopressors and inotropes between institutions.
Conclusions: Despite published guidelines, vasopressor and inotrope use in hemodynamic management of patients with sepsis and septic shock displayed much variability. Perceived incidence of ADRs for these agents also demonstrated inconsistency among respondents. National organizations need to develop recommendations for standardization of concentrations of continuous infusion medications in the ICU.


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Measurement of Central Venous Pressure via the Femoral Route in Abdominal Compartment Syndrome

Introduction: Femoral vein catheterization provides an alternative route of access to central veins, is technically easy and relatively safe. There is good evidence of a general agreement between intrathoracic central venous pressure (CVP) and CVP measured in the iliofemoral veins or inferior vena cava in critically ill patients. This agreement is not well documented when intra-abdominal pressure is raised.
Methods: Intra-abdominal and intrathoracic venous pressures were measured in two cases of abdominal compartment syndrome (ACS), who both had intrathoracic and femoral central venous catheters in place for clinical management. A PUBMED search was conducted to identify relevant studies or reports documenting the relationship between intrathoracic and intra-abdominal CVP, with special reference to conditions of raised intraabdominal pressure or ACS.
Results: There are several sources of data confirming that under conditions of normal to moderately raised intra-abdominal pressure there is a close relationship between intrathoracic CVP and intraabdominal CVP in critically ill patients, even during mechanical ventilation. There is little data documenting the relationship under conditions of raised intra-abdominal pressure, and no data under conditions of ACS. The two cases reported suggest that the normal close relationship is completely lost under conditions of ACS.
Conclusions: Vascular catheters inserted via the femoral route can be routinely used to measure CVP in most critically ill patients with normal or moderately raised intra-abdominal pressure (<15-20 mmHg), but should not be used to measure CVP in patients with abdominal compartment syndrome.


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Diltiazem versus Amiodarone for New-Onset Atrial Arrhythmias in Non-Cardiac Post Surgical Patients: A Cohort Study

Objective: To evaluate safety and efficacy of diltiazem versus amiodarone for conversion of atrial arrhythmias in non-cardiac post-surgical critically ill patients.
Design: A cohort study of non-cardiac post surgical patients admitted to the surgical intensive care unit with new-onset atrial tachyarrhythmias which were treated by protocol. In the first year patients were treated with diltiazem, and amiodarone was used in
the second year.
Setting: Thirty-eight bed surgical intensive care unit in a university medical center. Patients and participants: Sixty-one patients were treated for new-onset atrial tachyarrhythmias: 31
received diltiazem and 30 received amiodarone.
Interventions: Diltiazem loading dose 0.25 mg/kg and continuous infusion or amiodarone 150 mg loading dose and continuous infusion.
Measurements and results: Both groups had comparable demographics. Neither 24-hour conversion rates (diltiazem 87.1%, amiodarone
86.7%, p =0.96) nor mean times (±Standard Deviation) to conversion were statistically different (diltiazem 6.9±6.3 hours versus amiodarone 5.0±4.2 hours, p =0.52). Three patients developed hypotension (diltiazem 1, amiodarone 2, p =0.57).
Conclusions: Amiodarone and diltiazem led to no differences for treating atrial tachyarrhythmias in non-cardiac surgical patients based on safety and efficacy. Randomized controlled studies are
needed to compare diltiazem versus amiodarone for conversion of postoperative atrial fibrillation.


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