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1. Current use of inotropes in circulatory shock

Author

Michael R. Pinsky, Maria Cronhjort, Thomas Kaufmann, Rupert M Pearse, Ludhmila Abrahão Hajjar, Daniel A. Reuter, Jean Louis Vincent, Daniel De Backer, Martin W. Dünser, Maurizio Cecconi, Xavier Monnet, Iwan C. C. van der Horst, Vanina Siham Kanoore Edul, Bernard Cholley, Claude Martin, Thomas Scheeren, Yasser Sakr, Philippe Vignon, Didier Payen, Olfa Hamzaoui, Bernd Saugel, E. Christiaan Boerma, Pierre Squara, Alexandre Mebazaa, Geert Koster, Djillali Annane, Andrea Morelli, Arnaldo Dubin, Marc Leone, Pierre Asfar, Mervyn Singer, Anthony C. Gordon, Jan Bakker, Antoine Vieillard-Baron, Giovanni Landoni, Michael Sander, Michelle S Chew, Jean-Louis Teboul, Simon T. Vistisen, Glenn Hernandez, Peter Radermacher, Jacques Duranteau, Bruno Levy, Critical care, Anesthesiology, Peri-operative and Emergency medicine (CAPE), RS: Carim - V04 Surgical intervention, Intensive Care, MUMC+: MA Medische Staf IC (9), MUMC+: MA Intensive Care (3), University of Groningen [Groningen], University Medical Center Groningen [Groningen] (UMCG), New York University Langone Medical Center (NYU Langone Medical Center), NYU System (NYU), Columbia University Medical Center (CUMC), Columbia University [New York], Erasmus University Medical Center [Rotterdam] (Erasmus MC), Hôpital Raymond Poincaré [AP-HP], Université de Versailles Saint-Quentin-en-Yvelines - UFR Sciences de la santé Simone Veil (UVSQ Santé), Université de Versailles Saint-Quentin-en-Yvelines (UVSQ), Centre Hospitalier Universitaire d'Angers (CHU Angers), PRES Université Nantes Angers Le Mans (UNAM), MitoVasc - Physiopathologie Cardiovasculaire et Mitochondriale (MITOVASC), Université d'Angers (UA)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Centre National de la Recherche Scientifique (CNRS), Medical Centre Leeuwarden, Istituto Clinico Humanitas [Milan] (IRCCS Milan), Humanitas University [Milan] (Hunimed), Linköping University (LIU), Hôpital Européen Georges Pompidou [APHP] (HEGP), Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Hôpitaux Universitaires Paris Ouest - Hôpitaux Universitaires Île de France Ouest (HUPO), Université Paris Cité - UFR Médecine [Santé] (UPCité UFR Médecine), Université Paris Cité (UPCité), Karolinska Institutet [Stockholm], Centre Hospitalier Interrégional Edith Cavell (CHIREC), Universidad Nacional de la Plata [Argentine] (UNLP), Johannes Kepler University Linz [Linz] (JKU), Kepler University Hospital, AP-HP Hôpital Bicêtre (Le Kremlin-Bicêtre), Imperial College London, Universidade de São Paulo = University of São Paulo (USP), AP-HP - Hôpital Antoine Béclère [Clamart], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP), Pontificia Universidad Católica de Chile (UC), Hospital Juan A. Fernandez [Buenos Aires, Argentina], Universita Vita Salute San Raffaele = Vita-Salute San Raffaele University [Milan, Italie] (UniSR), Hôpital Nord [CHU - APHM], Défaillance Cardiovasculaire Aiguë et Chronique (DCAC), Centre Hospitalier Régional Universitaire de Nancy (CHRU Nancy)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Lorraine (UL), Département d’Anesthésie-Réanimation-SMUR [Hôpital Lariboisière], Hôpitaux Universitaire Saint-Louis, Lariboisière, Fernand-Widal, Centre de Référence de l’Hypertension Pulmonaire Sévère [CHU Le Kremlin Bicêtre], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-AP-HP Hôpital Bicêtre (Le Kremlin-Bicêtre), Ecotaxie, microenvironnement et développement lymphocytaire (EMily (UMR_S_1160 / U1160)), Institut National de la Santé et de la Recherche Médicale (INSERM)-Université Paris Cité (UPCité), Hôpital Lariboisière-Fernand-Widal [APHP], William Harvey Research Institute, Barts and the London Medical School, Queen Mary University of London (QMUL), University of Pittsburgh Medical Center [Pittsburgh, PA, États-Unis] (UPMC), Universitätsklinikum Ulm - University Hospital of Ulm, University Medical Center Rostock, Jena University Hospital [Jena], Justus-Liebig-Universität Gießen = Justus Liebig University (JLU), Universitaetsklinikum Hamburg-Eppendorf = University Medical Center Hamburg-Eppendorf [Hamburg] (UKE), University College of London [London] (UCL), Clinique Ambroise Paré [Centres Médico-Chirurgicaux Ambroise Pré, Pierre Cherest, Hartmann], Centre de recherche en épidémiologie et santé des populations (CESP), Université de Versailles Saint-Quentin-en-Yvelines (UVSQ)-Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Hôpital Paul Brousse-Institut National de la Santé et de la Recherche Médicale (INSERM)-Université Paris-Saclay, Centre d'Investigation Clinique de Limoges (CIC1435), CHU Limoges-Institut National de la Santé et de la Recherche Médicale (INSERM), Université libre de Bruxelles (ULB), Maastricht University Medical Centre (MUMC), Maastricht University [Maastricht], Aarhus University Hospital, European Society of Intensive Care Medicine, ESICM, This work has received the endorsement of the European Society of Intensive Care Medicine. The authors would like to thank Hannah Wunsch and Anders Perner, who provided their expertise as experts but abstained from being listed as co-author of this paper., HAL UVSQ, Équipe, NIHR, Scheeren, T. W. L., Bakker, J., Kaufmann, T., Annane, D., Asfar, P., Boerma, E. C., Cecconi, M., Chew, M. S., Cholley, B., Cronhjort, M., De Backer, D., Dubin, A., Dunser, M. W., Duranteau, J., Gordon, A. C., Hajjar, L. A., Hamzaoui, O., Hernandez, G., Kanoore Edul, V., Koster, G., Landoni, G., Leone, M., Levy, B., Martin, C., Mebazaa, A., Monnet, X., Morelli, A., Payen, D., Pearse, R. M., Pinsky, M. R., Radermacher, P., Reuter, D. A., Sakr, Y., Sander, M., Saugel, B., Singer, M., Squara, P., Vieillard-Baron, A., Vignon, P., Vincent, J. -L., van der Horst, I. C. C., Vistisen, S. T., and Teboul, J. -L.

Subjects
Inotrope, PDE-inhibitors, Levosimendan, [SDV]Life Sciences [q-bio], 030204 cardiovascular system & hematology, Critical Care and Intensive Care Medicine, GUIDELINES, 0302 clinical medicine, Catecholamines, CARDIAC-OUTPUT SYNDROME, Septic shock, Inotropes, Cardiogenic shock, lcsh:Medical emergencies. Critical care. Intensive care. First aid, Acute circulatory failure, 3. Good health, [SDV] Life Sciences [q-bio], Shock (circulatory), Sepsis, Resuscitation, Vasoactive agents, Cardiac output, medicine.symptom, Life Sciences & Biomedicine, CRITICALLY-ILL PATIENTS, medicine.drug, medicine.medical_specialty, Anestesi och intensivvård, Medicina, Context (language use), VASOPRESSORS, 1117 Public Health and Health Services, 03 medical and health sciences, Critical Care Medicine, acute circulatory failure, cardiac output, cardiogenic shock, catecholamines, inotropes, levosimendan, resuscitation, sepsis, septic shock, vasoactive agents, General & Internal Medicine, Anesthesiology, medicine, Intensive care medicine, METAANALYSIS, Science & Technology, Anesthesiology and Intensive Care, business.industry, Research, 1103 Clinical Sciences, 030208 emergency & critical care medicine, lcsh:RC86-88.9, Guideline, medicine.disease, DYSFUNCTION, CARDIOGENIC-SHOCK, Dobutamine, business
Abstract

Background: Treatment decisions on critically ill patients with circulatory shock lack consensus. In an international survey, we aimed to evaluate the indications, current practice, and therapeutic goals of inotrope therapy in the treatment of patients with circulatory shock. Methods: From November 2016 to April 2017, an anonymous web-based survey on the use of cardiovascular drugs was accessible to members of the European Society of Intensive Care Medicine (ESICM). A total of 14 questions focused on the profile of respondents, the triggering factors, first-line choice, dosing, timing, targets, additional treatment strategy, and suggested effect of inotropes. In addition, a group of 42 international ESICM experts was asked to formulate recommendations for the use of inotropes based on 11 questions. Results: A total of 839 physicians from 82 countries responded. Dobutamine was the first-line inotrope in critically ill patients with acute heart failure for 84% of respondents. Two-thirds of respondents (66%) stated to use inotropes when there were persistent clinical signs of hypoperfusion or persistent hyperlactatemia despite a supposed adequate use of fluids and vasopressors, with (44%) or without (22%) the context of low left ventricular ejection fraction. Nearly half (44%) of respondents stated an adequate cardiac output as target for inotropic treatment. The experts agreed on 11 strong recommendations, all of which were based on excellent (> 90%) or good (81–90%) agreement. Recommendations include the indications for inotropes (septic and cardiogenic shock), the choice of drugs (dobutamine, not dopamine), the triggers (low cardiac output and clinical signs of hypoperfusion) and targets (adequate cardiac output) and stopping criteria (adverse effects and clinical improvement). Conclusion: Inotrope use in critically ill patients is quite heterogeneous as self-reported by individual caregivers. Eleven strong recommendations on the indications, choice, triggers and targets for the use of inotropes are given by international experts. Future studies should focus on consistent indications for inotrope use and implementation into a guideline for circulatory shock that encompasses individualized targets and outcomes., La lista completa de autores que integran el documento puede consultarse en el archivo., Facultad de Ciencias Médicas

Published
2020

2. Use of explicit ICD9-CM codes to identify adult severe sepsis: impacts on epidemiological estimates

Author

J. M. Amate-Blanco, Teresa López-Cuadrado, Carmen Bouza, Plan Nacional de I+D+i (España), Ministerio de Sanidad Política Social e Igualdad (España), Funding was provided by the Spanish National I + D Programme (grant number STPY 1346/09). The funding body had no further role in study design, data collection, analysis, interpretation, writing of the report or the decision to submit the paper for publication., Ministerio de Economía y Competitividad (España), and Ministerio de Sanidad, Servicios Sociales e Igualdad (España)

Subjects
Male, medicine.medical_specialty, Epidemiology, Administrative data, Critical Care and Intensive Care Medicine, Cohort Studies, 03 medical and health sciences, 0302 clinical medicine, International Classification of Diseases, Sepsis, Internal medicine, Humans, Medicine, Health services research, 030212 general & internal medicine, Severe sepsis, Aged, Outcome, Surveillance, business.industry, Mortality rate, Incidence (epidemiology), Incidence, Organ dysfunction, Hospital discharge database, 030208 emergency & critical care medicine, Middle Aged, Epidemiologic Studies, Editorial, Spain, Relative risk, Cohort, Emergency medicine, Female, medicine.symptom, Trends, business
Abstract

Background: Severe sepsis is a challenge for healthcare systems, and epidemiological studies are essential to assess its burden and trends. However, there is no consensus on which coding strategy should be used to reliably identify severe sepsis. This study assesses the use of explicit codes to define severe sepsis and the impacts of this on the incidence and in-hospital mortality rates. Methods: We examined episodes of severe sepsis in adults aged ≥18 years registered in the 2006–2011 national hospital discharge database, identified in an exclusive manner by two ICD-9-CM coding strategies: (1) those assigned explicit ICD-9-CM codes (995.92, 785.52); and (2) those assigned combined ICD-9-CM infection and organ dysfunction codes according to modified Martin criteria. The coding strategies were compared in terms of the populations they defined and their relative implementation. Trends were assessed using Joinpoint regression models and expressed as annual percentage change (APC). Results: Of 222 846 episodes of severe sepsis identified, 138 517 (62.2 %) were assigned explicit codes and 84 329 (37.8 %) combination codes; incidence rates were 60.6 and 36.9 cases per 100 000 inhabitants, respectively. Despite similar demographic characteristics, cases identified by explicit codes involved fewer comorbidities, fewer registered pathogens, greater extent of organ dysfunction (two or more organs affected in 60 % versus 26 % of cases) and higher in-hospital mortality (54.5 % versus 29 %; risk ratio 1.86, 95 % CI 1.83, 1.88). Between 2006 and 2011, explicit codes were increasingly implemented. Standardised incidence rates in this cohort increased over time with an APC of 12.3 % (95 % CI 4.4, 20.8); in the combination code cohort, rates increased by 3.8 % (95 % CI 1.3, 6.3). A decreasing trend in mortality was observed in both cohorts though the APC was −8.1 % (95 % CI −10.4, −5.7) in the combination code cohort and −3.5 % (95 % CI −3.9, −3.2) in the explicit code cohort. Conclusions: Our findings suggest greater and increasing use of explicit codes for adult severe sepsis in Spain. This trend will have substantial impacts on epidemiological estimates, because these codes capture cases featuring greater organ dysfunction and in-hospital mortality. We especially thank the Subdirección General de Información Sanitaria (Ministry of Health, Social Services and Equality) for providing the data used in this study. Funding was provided by the Spanish National I + D Programme (grant number STPY 1346/09). The funding body had no further role in study design, data collection, analysis, interpretation, writing of the report or the decision to submit the paper for publication. Sí

Published
2016