The patient with acute cardiovascular problems
Peate Ian, Dutton Helen in Acute Nursing Care, 2020
The priorities are to restore adequate perfusion to the vital organs and to reduce the workload of the heart. As the primary problem is the inability of the heart to provide sufficient cardiac output to achieve organ perfusion, these priorities are interrelated. By improving cardiac output, there should be a corresponding increase in perfusion pressure. However, the restoration of myocardial function might require a number of supportive therapies that can only be provided in a critical care environment, such as: Inotropic drugs.Intra-aortic balloon counter pulsation.Ventricular assist device (VAD)/temporary mechanical circulatory support such as extra corporeal membrane oxygenation (ECMO).
Acute coronary syndrome with haemodynamic instability
K Sarat Chandra, AJ Swamy in Acute Coronary Syndromes, 2020
Vasopressors and inotropes: Sympathomimetic inotropic and vasopressor agents remain the mainstay of first-line therapy. However, all these agents increase cardiac work and raise the PCWP, hence the minimum required dose should be used [21]. The indication and dosage of various vasopressors is given in Table 21.2. Norepinephrine is a potent vasopressor with some positive inotropic properties that may be used for rapid initial circulatory support for CS.Dopamine has its effects based upon the dose administered. At low doses, it has primarily positive inotropic effects but at higher doses it stimulates alpha adrenergic receptors, resulting in vasoconstriction and increased systemic vascular resistance. High dosage results in undesirable elevation in pulmonary capillary wedge pressure (PCWP). While historically dopamine has been chosen before norepinephrine, some evidence suggests that outcomes may be better with norepinephrine.Dobutamine may be used in less sick patients with a low cardiac index and high PCWP but without severe hypotension (e.g. systolic blood pressure >80 mmHg).
Cardiovascular Medications in Pregnancy
Afshan B. Hameed, Diana S. Wolfe in Cardio-Obstetrics, 2020
Management of acute heart failure and cardiogenic shock in pregnancy is based on current heart failure guidelines. Diuretics such as furosemide, bumetanide, and hydrochlorothiazide are used for symptomatic pulmonary edema and, as mentioned before, hold the risk of decreasing placental perfusion and causing an electrolyte imbalance in the fetus. For afterload reduction, hydralazine plus nitrates are used in place of ACE inhibitors and ARBs. After initial stabilization, beta blockers should be initiated, and digoxin can be considered. Postpartum, neurohormonal blockade can be restarted [1]. Paucity of data and lack of guidelines exist in regard to inotrope and vasopressor use for the critically ill pregnant patient. For inotrope support, dopamine and dobutamine have been safely used in pregnancy (119). Levosimendan, a calcium sensitizer, is recommended in the setting of postpartum cardiomyopathy, as dobutamine may be associated with heart failure progression in these patients [31].
Predictors for short-term successful weaning from continuous renal replacement therapy: a systematic review and meta-analysis
Published in Renal Failure, 2023
Yu Li, Xiaoqi Deng, Jiaxing Feng, Bo Xu, Yulei Chen, Zhanying Li, Xiaodan Guo, Tianjun Guan
The predictive accuracy of serum creatinine at the cessation of CRRT has been previously assessed [21,22,25,29]. According to our result, we are inclined to believe serum creatinine at the cessation of CRRT is a predictor for successful weaning from CRRT. However, our pooled analysis result was not robust with high heterogeneity. This could be due to the limited number of included studies, or the effect size of the change (per 1 μmol/L increase) is too small to explain the observed changes. In addition, serum creatinine levels are affected by many factors (e.g., muscle mass, gender, race, the timing of cessation of CRRT). As for the use of diuretics, we are inclined to believe that patients reduced demand on re-initiation of RRT with enhanced diuresis therapeutic strategy, due to less fluid accumulation after the termination of CRRT. However, the result should be carefully interpreted because of the significant heterogeneity among studies, and some of the heterogeneity may be due to the different types of diuretics and management strategies. It is commonly accepted that maintenance of appropriate blood pressure with vasopressor or inotrope brings clinical benefits, but more studies are needed to verify the relationship between drug use and short-term successful weaning from CRRT due to the heterogeneity.
Intraoperative vasopressor use and early postoperative acute kidney injury in elderly patients undergoing elective noncardiac surgery
Published in Renal Failure, 2022
Dilshan Ariyarathna, Ajinkya Bhonsle, Joseph Nim, Colin K. L. Huang, Gabriella H. Wong, Nicholle Sim, Joy Hong, Kirrolos Nan, Andy K. H. Lim
In this study, 25.7% of elderly patients with a mean age of 75 years undergoing elective noncardiac surgery experienced at least one episode of SBP hypotension, and 7.8% experienced recurrent episodes. Most episodes of hypotension were brief, but the intraoperative use of vasopressor agents was high at 84.7%, and 11.5% received a relatively large total dose of vasopressors (>20 mg). One possible explanation for the high frequency of vasopressor and inotrope use is a preemptive approach taken by anesthetists based on declining blood pressure trends before it reached critical thresholds. We did not analyze for such trends, which may be an important consideration. A national or international study would be needed to determine if this observation was unique to our hospital network, or indeed very common practice in elective surgery. The mismatch between the frequency of documented hypotension and vasopressor use could also reflect under-documented hypotension, which is a possibility for episodes lasting <5 min which was rapidly corrected with a bolus of vasopressor agent.
Preclinical in vitro and in vivo pharmacokinetic properties of danicamtiv, a new targeted myosin activator for the treatment of dilated cardiomyopathy
Published in Xenobiotica, 2021
Mark P. Grillo, Svetlana Markova, Marc Evanchik, Marc Trellu, Patricia Moliner, Priscilla Brun, Anne Perreard-Dumaine, Pascale Vicat, Chun Yang, James P. Driscoll, Tim J. Carlson
Contemporary medical therapy for systolic heart failure (HFrEF) centers on counteracting the effects of neurohormonal activation with β-adrenergic blockers and modulators of the renin-angiotensin-aldosterone-system (Yancy et al. 2016). Although these drugs improve cardiovascular symptoms, none address the underlying myocardial dysfunction, nor do they reverse or fully arrest the gradual decline in cardiac function. This may be addressed directly with inotropic stimulation of the heart for which clinical therapies are available, but only for use in the inpatient setting. In addition, because these medications increase contractility at the price of increased myocardial energy and oxygen demand in a heart that is already challenged on these fronts, their use is limited to short-term therapy in patients with refractory heart failure. Indeed, chronic studies have demonstrated increased mortality due to arrhythmias and ischemia (Felker and O’Connor 2001). However, increased contractility does improve hemodynamics and symptoms, suggesting a potential clinical benefit for agents that increase contractility without additional energetic burden and the accompanying arrhythmic and ischemic liabilities.
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