A. Meier-hellmann

It was the purpose of this study to measure the relationship between hepatic venous O2 saturation (ShvO2) and mixed venous O2 saturation (SvO2) in septic patients (n = 21) following treatment with various catecholamines (epinephrine, norepinephrine, dopamine, dopexamine). At baseline mean SvO2 was 74 +/- 5% while mean ShvO2 was 59 +/- 12%. Alpha-mimetic substances such as epinephrine and norepinephrine reduced ShvO2 and increased the difference between SvO2 and ShvO2.Beta2-mimetic and dopaminergic substances (dopexamine, dopamine) did not change the difference between SvO2 and ShvO2. These results show that SvO2 does not necessarily reflect all changes of ShvO2. Monitoring ShvO2 may be helpful in managing septic shock by adding information on adequacy of O2 supply/consumption ratio in the crucial splanchnic region.

Rapid reversal of anticoagulant effect from the use of vitamin K antagonists (VKA) is essential when acute bleeding or emergency surgery occurs. Prothrombin complex concentrates (PCCs) produce a more rapid effect with a better clinical outcome, and do not cause volume overload as compared with fresh-frozen plasma (FFP). Octaplex is a modern, double virus safeguarded PCC with balanced content of vitamin K-dependent coagulation factors, which ensures fast onset of action and efficacious treatment, i.e. rapid correction of international normalized ratio (INR). The main purpose of this study was to demonstrate that Octaplex, when individually dosed, efficiently corrects INR to pre-determined levels in patients under oral anticoagulation who have bleeding complications or are undergoing invasive procedures. To measure the efficacy response, the INR achieved after PCC application per patient was calculated as geometric mean of three measurements within 1 h post-infusion. Sixty patients received a median total Octaplex dose of 41.1 (15.3-83.3) IU/kg body weight (bw). Of 56 patients evaluable in terms of efficacy, 51 (91%) showed a response as pre-defined in the protocol and in 52 (93%) the INR decreased to a value below 1.4 within one hour after dosing. The median INR declined from 2.8 (1.5-9.5) to 1.1 (1.0-1.9) within 10 min. All prothrombin complex coagulation factors recovered in parallel. Three patients had minor adverse drug reactions. One patient showed a non-symptomatic parvovirus B19 seroconversion. No thrombotic side effects were observed. Octaplex is efficacious and safe in immediate correction of dosage-dependent INR in patients with VKA-related deficiency of prothrombin complex coagulation factors.

Zusammenfassung   Hyperoxische Ventilation wird oft prophylaktisch angewandt. Dabei kommt es zu einem Abfall des globalen Sauerstoffverbrauchs (VO 2 ), bei kardialen Risikopatienten zu einer Exazerbation von myokardialen Ischämien. N-Azetylzystein (NAC) kann den VO 2 und die myokardiale Kontraktilität verbessern. Wir untersuchten, ob NAC unter Hyperoxie einen Einfluß auf klinische Parameter der Gewebeoxygenierung bei kardialen Risikopatienten hat. 30 Patienten, bei denen

To test whether dopamine infusion improves oxygen delivery (Do2) and oxygen uptake (VO2) in hyperdynamic septic shock patients stabilized by adequate volume and dobutamine alone, or by the combination of dobutamine and norepinephrine. Prospective clinical trial of two patient groups. Group 1 (n = 15) was stabilized with dobutamine, and group 2 (n = 10) was stabilized with dobutamine and norepinephrine. Intensive care unit in a university hospital. Twenty-five postoperative, hyperdynamic septic shock patients. The stabilizing catecholamine infusion was replaced in a stepwise manner by dopamine to achieve a similar mean arterial pressure (dopamine doses: group 1, mean 22 +/- 15 micrograms/kg/min [range 6 to 52]; and group 2, mean 57 +/- 41 micrograms/kg/min [range 15 to 130]). A complete hemodynamic profile was performed with oxygen transport-related variables at baseline, after replacement by dopamine, and after resetting to the original catecholamine infusion. The change to dopamine resulted in increases in cardiac index (group 1: 20% [p < .01]; group 2: 33% [p < .01]), and DO2 (group 1: 19% [p < .01]; group 2: 27% [p < .01]). However, VO2, whether directly measured from the respiratory gases or calculated by the cardiovascular Fick principle, did not change in both groups with dopamine, while the oxygen extraction ratio decreased significantly in both groups with dopamine. Heart rate, pulmonary artery occlusion pressure, and pulmonary shunt fraction all increased with dopamine. PaO2 decreased, but oxygen saturation remained stable in both groups with dopamine. Short-term dopamine infusion in hyperdynamic septic shock patients, despite producing higher global DO2, was not superior to dobutamine or the combination of dobutamine and norepinephrine infusion.

Multiple organ failure is the major cause of death in patients with sepsis. Bacterial translocation from the gut is considered to induce and maintain sepsis. Therefore, the splanchnic region plays an important role in the pathogenesis and treatment of sepsis. There is evidence for a very high risk of imbalance between oxygen delivery and oxygen consumption especially in the splanchnic region. Consequently, there is a crucial interest whether it is possible to influence the splanchnic perfusion by specific catecholamines. Unfortunately, only a few, conflicting studies have looked at the effects of the various catecholamines on regional blood flow. Therefore, a clear recommendation for a specific catecholamine regimen in septic shock is impossible. Furthermore, it is unknown whether the choice of a specific catecholamine in the treatment of septic shock affects the patient's outcome. In most patients, the use of vasopressors is indispensable because adequate haemodynamic perfusion pressure is not achieved with fluid therapy alone. The negative effects of vasopressors on splanchnic perfusion are known from studies carried out under non septic conditions. Norepinephrine and dopamine in doses of 10 micrograms/kg/min in septic animals are without negative effects on splanchnic perfusion. Preliminary results show Preliminary results show a decrease in splanchnic oxygenation in patients with septic shock treated with epinephrine. Catecholamines with beta mimetic effects are often used to increase DO2. The question as to whether dobutamine or dopamine should be used first in treatment of septic shock cannot be answered yet. Whether treatment with low dose dopamine or dopexamine actually improves renal function and splanchnic oxygenation is the purpose of ongoing studies.