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Query: UMLS:C0036690 (sepsis)
 59,461 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Isoproterenol, dobutamine, dopamine, and nitroprusside are four vasoactive drugs used to decrease pulmonary arterial pressure and increase cardiac output in newborns, infants, and children with sepsis. Thromboxane A2 likely produces some of the hemodynamic changes in sepsis, and U46619, a thromboxane A2 mimetic, produces similar changes in lambs. We studied the hemodynamic effects of these four vasoactive drugs in 10 spontaneously breathing newborn lambs during an infusion of U46619. After baseline hemodynamic measurements, U46619 (1-2 micrograms/kg/min) was infused to increase pulmonary arterial pressure and to decrease cardiac output. Then, either isoproterenol (0.05-1.0 micrograms/kg/min), dobutamine (5-20 micrograms/kg/min), dopamine (3-30 micrograms/kg/min), or nitroprusside (0.5-10.0 micrograms/kg/min) was infused. Every 10 min, measurements were repeated and the dose increased. U46619 significantly increased pulmonary arterial pressure by 182% and decreased cardiac output by 25% (p less than 0.05). Isoproterenol decreased pulmonary arterial pressure by 30% (p less than 0.05) and increased cardiac output by 25% (p less than 0.05) at low doses, and increased cardiac output by 115% at the maximum dose (p less than 0.05). Dobutamine decreased pulmonary arterial pressure by 11% (p less than 0.05) at low doses, and increased cardiac output by 28% (p less than 0.05) at low doses, and increased cardiac output by 71% at the maximum dose (p less than 0.05). Dopamine did not decrease pulmonary arterial pressure or increase cardiac output. Nitroprusside decreased pulmonary arterial pressure by 11% at the maximum dose (p less than 0.05). Isoproterenol and dobutamine may be more useful than dopamine and nitroprusside in the management of pulmonary hypertension and decreased cardiac output during sepsis.
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PMID:Effects of vasoactive drugs on thromboxane A2 mimetic-induced pulmonary hypertension in newborn lambs. 201 53

Dobutamine administration has been shown to increase oxygen delivery in various conditions, but there are little data to document its effects in septic shock. We investigated the effects of dobutamine infusion at a rate of 5 micrograms/kg.min in 18 patients (mean 60 +/- 16 yr) with septic shock initially characterized by hypotension, oliguria, and hyperlactatemia in the presence of a documented source of sepsis. Early resuscitation had consisted of fluid administration and vasopressors when required. When added to this standard regimen, dobutamine had no significant effect on mean arterial pressure (MAP) (from 71 +/- 12 to 73 +/- 13 mm Hg), but markedly increased cardiac index (from 3.0 +/- 0.7 to 3.9 +/- 1.0 L/min.m2, p less than .001), stroke index (from 32 +/- 8 to 37 +/- 9 ml/m2, p less than .001) and oxygen transport (from 410 +/- 105 to 530 +/- 146 ml/min.m2, p less than .001). Oxygen consumption (VO2) increased concurrently (from 137 +/- 42 to 162 +/- 66 ml/min.m2, p less than .002). MAP increased (from 68 +/- 9 to 76 +/- 11 mm Hg) in 12 patients and decreased moderately (from 76 +/- 18 to 69 +/- 17 mm Hg) in six patients. The two subgroups of patients had similar hemodynamic profiles before the dobutamine infusion, but vasopressor therapy was already used in one of the 12 patients in the first subgroup and in three of the six patients in the second subgroup (p less than .05).(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:Dobutamine administration in septic shock: addition to a standard protocol. 236 8

Hemodynamic and oxygen transport effects of dopamine and dobutamine were studied in a series of 25 critically ill postoperative general surgical patients by a prospective, randomized crossover design after maximal response to fluids had been obtained. Dopamine increased MAP, HR, CI, PvO2, DO2, and Qsp while decreasing PaO2. Dobutamine increased HR, CI, SI, stroke work, DO2, VO2, and Qsp while decreasing PAWP and SVRI and PVRI. In general, the effects of the two drugs were greater in patients in the first 72 hours after surgery. The effects of dobutamine on flow and oxygen transport were greater than those of dopamine, especially in the early postoperative period. The effects were smaller and not significant in patients more than three days after surgery, as well as in those with sepsis, respiratory failure, renal failure, age over 65 years, and hyperdynamic states, in part because of the small number of patients in each group. These data are consistent with the hypothesis that the beta 2-adrenergic action of dobutamine vasodilates the previously constricted peripheral circulation, enhances tissue perfusion by improving micro-circulatory flow distribution, and improves DO2 and VO2.
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PMID:Comparison of hemodynamic and oxygen transport effects of dopamine and dobutamine in critically ill surgical patients. 273 68

Dobutamine has been proposed as a means of disclosing a pathologic oxygen supply (DO2) dependency in critically ill patients. Like other catecholamines, however, dobutamine might increase cellular metabolism, so that oxygen consumption (VO2) would increase regardless of the presence or absence of a supply dependency. This study investigated the effects of graded doses of dobutamine on VO2 in stable, septic patients. Since it has been suggested that the use of reverse Fick equation to determine VO2 can induce a spurious VO2/DO2 dependency owing to a mathematical coupling of data, we determined VO2 both by respiratory gas analysis (VO2DIR) and from the reverse Fick equation (VO2INDIR). In 12 adult patients with signs of sepsis but an otherwise stable hemodynamic status (normal blood lactate levels, and no change in vasoactive drugs or fluid administration for at least 2 h), a dobutamine infusion was administered at a dose of up to 10 micrograms/kg/min in increments of 2 micrograms/kg/min every 10 min. Complete hemodynamic and gas measurements were obtained at baseline, at each dose of dobutamine, and 20 min after discontinuation of the infusion. All of the measured parameters were similar at baseline and after discontinuation of the dobutamine infusion. Dobutamine induced a dose-related increase in the cardiac index (from 3.84 +/- 0.97 to 6.19 +/- 1.56 L/min/m2, p < 0.01) and DO2 (from 501 +/- 123 to 801 +/- 219 ml/min/m2, p < 0.01). Both VO2DIR and VO2INDIR increased, from 161 +/- 37 to 183 +/- 40 ml/min/m2 and from 140 +/- 29 to 168 +/- 42 ml/min/m2, respectively (p < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:Effects of dobutamine on oxygen consumption in septic patients. Direct versus indirect determinations. 802 80

Decreases in gastric mucosal pH (pHi) are associated with splanchnic hypoxia in animals and with increased mortality in patients. In the present study we measured changes in gastric pHi with a tonometer in septic patients after a short-term infusion of dobutamine. These changes were compared with concurrent alterations in systemic O2 consumption (VO2) and arterial lactate. Twenty-one patients admitted sequentially to a medical intensive care unit with sepsis and gastric pHi < 7.32 were prospectively separated into a normal lactate group (< or = 2.2 mM; n = 10) and an elevated lactate group (> 2.2 mM; n = 11). Dobutamine HCl was infused intravenously at 5 micrograms/kg/min for approximately 3 h and then increased to 10 micrograms/kg/min. Measurements were obtained after each increase in the dose of dobutamine. Dobutamine infused at 10 micrograms/kg/min produced increases in O2 transport in both groups (p < 0.05) whereas systemic O2 consumption remained unchanged. These changes were accompanied by decreases in the arterial lactate concentration of the elevated lactate group (p < 0.01). Arterial lactate remained constant in the normal lactate group. Gastric pHi increased in both groups when dobutamine was infused at 5 micrograms/kg/min (p < 0.01), and then again at 10 micrograms/kg/min (p < 0.05). These results imply that regional tissue hypoxia, as characterized by a low gastric pHi, may be present in septic patients with normal arterial lactate concentration. Moreover, a rise in gastric pHi in response to increases in systemic O2 transport may be a better indicator of regional hypoxia in septic patients than related increases in systemic VO2.
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PMID:Effect of dobutamine on oxygen consumption and gastric mucosal pH in septic patients. 804 10

The optimal therapy for the treatment of sepsis and septic shock remains controversial. Many protocols are followed, using different strategies for initial resuscitation, cardiovascular monitoring, hemodynamic intervention, and eradication of infection. Overall, an aggressive approach to the management of cardiovascular dysfunction in septic shock is warranted. Initially, large volume fluid resuscitation is instituted. Our first choice of resuscitation fluid is 0.9% normal saline. Invasive hemodynamic monitoring using a flotation pulmonary artery catheter as well as invasive arterial blood pressure monitoring is a necessity in the hemodynamic management of septic shock. If the patient remains hypotensive (mean arterial pressure < 65 mm Hg) after adequate volume resuscitation has been established (pulmonary capillary wedge pressure 12 to 15 mm Hg), then vasopressor agents must be instituted. Our first choice is usually dopamine. In patients who remain hypotensive after maximal doses of dopamine are reached, norepinephrine is added. If these agents generate excessive tachycardia or if tachyarrhythmias develop, phenylephrine can be substituted or added. Inotropic agents are useful if the patient demonstrates hypotension with a low cardiac output state. Dobutamine is the agent of choice. We initiate broad-spectrum empiric antibiotics at presentation, modifying the exact regimen based on 1) site of infection; 2) prevailing organisms and antibiotic resistance patterns in the patient's environment; and 3) other specific risk factors (immunosuppression, chronic disease, exposure and vaccination history, invasive medical devices). When appropriate, aggressive surgical debridement is pursued. Currently, there are no clinical data to support the use of antagonists for sepsis mediators, although various clinical trials remain underway. Steroids are contraindicated except for adrenal replacement therapy.
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PMID:Cardiovascular Dysfunction in Sepsis and Septic Shock. 1109 49

Key elements of the current approach to treating sepsis are reviewed, and examples are given to illustrate the difficulty of designing and evaluating trials in sepsis. A patient with sepsis is likely to have symptoms characteristic of the systemic inflammatory response syndrome. Initially, ruling out noninfective causes, locating the site of infection, and obtaining cultures before beginning antimicrobial therapy are critical. Aggressive fluid resuscitation and hemodynamic support are used to restore tissue perfusion and normalize cellular metabolism. Vasopressor therapy with dopamine or norepinephrine is needed in patients unresponsive to fluid resuscitation. Dobutamine should be administered in patients whose cardiac output is inadequate despite optimization of fluids and pressors. Supportive care includes deep vein thrombosis prophylaxis, nutrition support, stress ulcer prophylaxis, and management of acute lung injury. Attempts to modify the sepsis response and improve the outcome in these patients have yielded limited benefits. Recent small studies have shown benefits with low-dose hydrocortisone in patients with refractory sepsis. One challenge in study design is that a therapy may target a subset of patients that cannot be identified at the outset. Management of patients with suspected or documented sepsis focuses on hemodynamic support, appropriate antimicrobial therapy, and other supportive care.
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PMID:Current strategies for managing the patient with sepsis. 1188 13

Dopamine is used in the clinical setting to support cardiac output and blood pressure and to improve diuresis. Experimental studies suggest that dopamine may reduce splanchnic perfusion and redistribute blood flow locally. To assess the effects of dopamine on splanchnic perfusion, we used dopamine to increase cardiac output by 25% in nine septic patients and 11 patients after cardiac surgery. Systemic (pulmonary artery catheter) and splanchnic (hepatic vein catheter and dye dilution) hemodynamics and oxygen transport were measured at baseline and 90 min after increasing the cardiac output. Dopamine infusion [in cardiac surgery patients 4.2 (1.4-8.5) microg x kg(-1) x min(-1) (median, range) and in septic patients 4.0 (2.1-9.0) microg x kg(-1) x min(-1)] increased splanchnic blood flow in cardiac surgery patients from 0.61 (0.13) L x min(-1) x m(-2) to 0.82 (0.13) L x min(-1) x m(-2) [mean (standard deviation; SD); P = 0.018] and in septic patients from 0.91 (0.32) L x min(-1) x m(-2) to 1.12 (0.40) L x min(-1) x m(-2) (P = 0.038). Splanchnic oxygen consumption increased in cardiac surgery patients from 39 (5) mL x min(-1) x m(-2) to 46 (6) mL x min(-1) x m(-2) (P = 0.003) but decreased in septic patients from 61 (19) mL x min(-1) x m(-2) to 51 (17) L x min(-1) x m(-2) (p = 0.021). Because of the unexpected results, we compared these data post hoc with data obtained from another group of 15 septic patients with acute lung injury, where dobutamine was used to increase cardiac output in a similar design. Dobutamine in these patients [6.4 (4.2-9.5) microg x kg(-1) x min(-1)] increased splanchnic blood flow from 1.20 (0.44) L x min(-1) x m(-2) to 1.43 (0.57) L x min(-1) x m(-2) (P = 0.008), while splanchnic oxygen consumption did not change 72 (25) mL x min(-1) x m(-2) vs. 76 (22) mL x min(-1) x m(-2) (not significant)]. The reduction of splanchnic oxygen consumption by dopamine in sepsis suggests an impairment of hepatosplanchnic metabolism despite an increase in regional perfusion. The safety and indications of dopamine use in sepsis should be re-evaluated.
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PMID:Effects of dopamine on systemic and regional blood flow and metabolism in septic and cardiac surgery patients. 1209 39

"Severe sepsis" is defined by organ dysfunction due to infection-induced hypoperfusion. "Septic shock" is defined by hypotension refractory to fluid resuscitation, associated with organ dysfunctions or hypoperfusion. Mortality from severe sepsis and from septic shock is high. Guidelines to help physicians improve the survival of patients with severe sepsis comprise one part of an international project called the Surviving Sepsis Campaign. They bring together treatment innovations based on monitoring aimed at ensuring comprehensive management of tissue oxygen levels (central venous oxygen saturation: SvcO2). They are based on the optimization of early treatment, during the first six hours of severe sepsis, and ensuring no delay in fluid resuscitation. In case of septic shock, fluid resuscitation must be rapidly accompanied by administration of vasoconstrictive catecholamines. Noradrenaline is preferred to dopamine. Dobutamine is recommended when the cardiac index is less than 2.5 L x min(-1) x m(-2). Because of the relative adrenal insufficiency that occurs during septic shock, corticoids are recommended, after a synacthen test. Activated protein C is currently the only therapy produced by biotechnology that reduces mortality from severe sepsis. Global management of septic shock must form an integral part of resuscitation guidelines and include protocols for, among other things, sedation, ventilation, strict glycemic control, and prophylaxis for deep vein thrombosis and stress ulcers.
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PMID:[Non-infective treatments for septic shock]. 1678 62

The severe impairment of the microcirculation plays a substantial role in the pathogenesis of severe sepsis and septic shock, and leads to multiple organ failure and death. Therapeutic strategies to resuscitate the microcirculatory blood flow and to improve the functional capillar density are therefore essential to surmount the microcirculatory pathology and to avoid tissue hypoxia. Based on reasonable scientific evidence, early fluid resuscitation directed by defined haemodynamic and metabolic goals (EGDT) as well as the application of activated protein C (rhAPC) according to the guidelines could be recommended. Dobutamine is the first choice to improve cardiac output and to overcome myocardial depression in septic shock whereas phosphodiesterase-III-inhibitors and levosimendane are still experimental options. Furthermore selective inhibitors of iNOS, nitroglycerol, as well as vasopressin have to be investigated relating to their specific effects on the microcirculation and their influence on survival in seevere sepsis and septic shock.
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PMID:[Therapeutic options to improve the microcirculation in sepsis and septic shock]. 1727 78


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