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Re: Dobutamine and terlipressin in patients with septic shock
- Andrea Morelli (4 May 2008)
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Dobutamine and terlipressin in patients with septic shock
- Ashley Miller, Nick Coleman (23 April 2008)
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Andrea Morelli
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Editor, We thank Dr Miller and Dr Coleman for their relevant comment on our recent publication in British Journal of Medicine. One of the most important endpoints of our study was to evaluate the effects of terlipressin alone or in combination with dobutamine on oxygen delivery and oxygen consumption. Since virtually all patients included in the trial presented with or were at risk for pulmonary arterial hypertension, we decided to perform hemodynamic monitoring by the means of a pulmonary artery catheter. It is well known that cardiac output can also be determined by pulse contour analyses, transpulmonary thermodilution or echocardiography. In fact, dynamic variables, such as systolic pressure variation, pulse pressure variation, stroke volume variation and changes in cardiac index in response to a fluid challenge might be more useful in guiding fluid resuscitation than static parameters. However, the current sepsis guidelines suggest to perform fluid therapy aiming to preserve central venous pressure at 8-12 mmHg, mean pulmonary occlusion pressure between 12 and 15 mmHg, and a SvO2 (if available) of at least 65 %. Since we wanted to comply with the guidelines, we performed fluid therapy to achieve these endpoints. It might be argued that some patients with high catecholamine doses benefit from PAOP values > 12-15 mmHg (especially in the presence of myocardial diastolic dysfunction). In this regard it is important to note that mean PAOP was consistently within the upper limit of this range (between 14 and 16 mmHg). Moreover, it has to be underlined that the thermodilution technique is still referred to as the gold standard of cardiac output measurement. Since dynamic parameters may be more accurate predictors of volume responsiveness in septic shock patients, they will hopefully be implemented into the next guidelines. Andrea Morelli, Christian Ertmer and Martin Westphal Conflict of Interest:None declared |
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Ashley Miller , Nick Coleman
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Editor - I read with interest the study by Morelli and colleagues describing the simultaneous infusion of dobutamine and terlipressin in patients with septic shock. The criteria chosen in the study to demonstrate adequate fluid resuscitation were a pulmonary artery occlusion pressure (PAOP) of 12-15mm Hg and a central venous pressure (CVP) of 8-12 mm Hg. While these are traditional and theoretical markers of intravascular filling, it has been clearly and repeatedly demonstrated that a static CVP or PAOP reading is not an indication of either the adequacy of intravascular volume, or of fluid responsiveness. 1 This holds true in experimental animal models of hypovolaemic shock 2, normal volunteers 3, septic patients 4, intensive care patients 5 and cardiac surgery patients.6 7 There is increasing evidence that dynamic criteria such as respiratory variations in haemodynamic variables (systolic pressure variation 8 , pulse pressure variation 9 10, stroke volume variation 11 12), the effect of passive leg raising 13 and changes in CI in response to a fluid challenge 14 are far more useful in guiding fluid resuscitation than their static counterparts. It is likely that at least some of the patients in this trial would have shown evidence of fluid responsiveness had dynamic criteria for this been used. Vasoconstricting patients who are not adequately fluid resuscitated is likely to be detrimental via a reduction in cardiac index (CI) and may compromise tissue oxygen delivery. There may have been a smaller reduction in SvO2 and CI in the terlipressin groups and less subsequent dobutamine use if a more evidenced based method of fluid resuscitation had been used. A. Miller* N. Coleman Stoke-on-Trent, UK E-mail: admin@cmc.myzen.co.uk References 1 Michard F, Treboul JL: Predicting fluid responsiveness in ICU patients: a critical analysis of the evidence. Chest 2002; 121: 2000-8 2 Nouira S, Elatrous S, Dimassi S, Besbes L, Boukef R, Mohamed B, Abroug F. Effects of norepinephrine on static and dynamic preload indicators in experimental hemorrhagic shock. Crit Care Med 2005; 33: 2339 -2343. 3 Kumar, Anand, Anel, Ramon, Bunnel, Eugene, Habet, Kalim, Zanotti, Sergio, Marshall, Stephanie, Neumann, Alex, Ali, Amjad, Cheang, Mary, Kavinsky, Clifford, Parrillo, Joseph. Pulmonary artery occlusion pressure and central venous pressure fail to predict ventricular filling volume, cardiac performance, or the response to volume infusion in normal subjects. Crit Care Med 2004; 32: 691-699 4 Osman D, Ridel C, Ray P, Monnet X, Anguel N, Richard C, Teboul JL. Cardiac filling pressures are not appropriate to predict haemodynamic response to volume challenge. Crit Care Med 2007; 35: 64-68 5 Benjamin E, Griffin K, Leibowitz AB, et al. Goal-directed transesophageal echocardiography performed by intensivist to assess left ventricular function: comparison with pulmonary artery catheterization. J Cardiothorac Vasc Anesth 1998; 12: 10–5 6 Buhre W, Weyland A, Schorn B, Scholz M, Kazmaier S, Hoeft A, Sonntag H. Changes in central venous pressure and pulmonary capillary wedge pressure do not indicate changes in right and left heart volume in patients undergoing coronary artery bypass surgery. Eur J Anesthesiol 1999; 16: 11-17. 7 Godje O, Peyerl M, Seebauer T, Lamm P, Mair H, Reichart B. Central venous pressure, pulmonary capillary wedge pressure and intrathoracic blood volumes as preload indicators in cardiac surgery patients. Eur J Cardiothorac Surg 1998; 13: 533-539 8 Perel A: The physiological basis of arterial pressure variation during positive-pressure ventilation. Reanimation 2005; 14: 162-71 9 Michard F, Boussat S, Chemla D, Anguel N, Mercat A, Lecarpentier Y, Richard C, Pinsky MR, Teboul JL. Relation between respiratory changes in arterial pulse pressure and fluid responsiveness in septic patients with acute circulatory failure. Am J Respir Crit Care Med 2000; 162: 134-138 10 Bendjelid K, Suter PM, Romand JA: The respiratory change in preejection period: a new method to predict fluid responsiveness. J Appl Physiol 2004; 96: 337-42 11 Marx G, Cope T, McCrossan L, et al. Assessing fluid responsiveness by stroke volume variation in mechanically ventilated patients with severe sepsis. Eur J Anaesthesiol 2004; 21: 132–8 12 Berkenstadt H, Margalit M, Hadani M, et al. Stroke volume variation as a predictor of fluid responsiveness in patients undergoing brain surgery. Anesth Analg 2001; 92: 984–9 13 Monnet X, Rienzo M, Osman D, Anguel N, Richard C, Pinsky MR, Teboul JL. Passive leg raising predicts fluid responsiveness in the critically ill. Crit Care Med 2006, 34: 1402-1407 14 Venn R, Steele A, Richardson P, Poloniecki J, Grounds M, Newman P: Randomized controlled trial to investigate influence of the fluid challenge on duration of hospital stay and perioperative morbidity in patients with hip fractures. Br J Anaesth 2002, 88: 65-71 Conflict of Interest:None declared |
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