Thomas W L Scheeren1, Jan Bakker2,3,4,5, Thomas Kaufmann6, Djillali Annane7, Pierre Asfar8, E Christiaan Boerma9, Maurizio Cecconi10,11, Michelle S Chew12, Bernard Cholley13,14, Maria Cronhjort15, Daniel De Backer16, Arnaldo Dubin17, Martin W Dünser18, Jacques Duranteau19, Anthony C Gordon20, Ludhmila A Hajjar21, Olfa Hamzaoui22, Glenn Hernandez23, Vanina Kanoore Edul24, Geert Koster25, Giovanni Landoni26, Marc Leone27, Bruno Levy28, Claude Martin27, Alexandre Mebazaa29, Xavier Monnet30,31, Andrea Morelli32, Didier Payen33, Rupert M Pearse34, Michael R Pinsky35, Peter Radermacher36, Daniel A Reuter37, Yasser Sakr38, Michael Sander39, Bernd Saugel40, Mervyn Singer41, Pierre Squara42, Antoine Vieillard-Baron43,44, Philippe Vignon45,46, Jean-Louis Vincent47, Iwan C C van der Horst48, Simon T Vistisen49,50, Jean-Louis Teboul30,31. 1. Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, P.O.Box 30.001, 9700 RB, Groningen, The Netherlands. t.w.l.scheeren@umcg.nl. 2. New York University Medical Center, New York, USA. 3. Columbia University Medical Center, New York, USA. 4. Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands. 5. Pontificia Universidad Católica de Chile, Santiago, Chile. 6. Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, P.O.Box 30.001, 9700 RB, Groningen, The Netherlands. 7. School of Medicine Simone Veil, Raymond Poincaré Hospital (APHP), Department of Intensive Care Medicine, University of Versailles- University Paris Saclay, Garches, France. 8. Département de Médecine Intensive-Réanimation Et de Médecine Hyperbare, Centre Hospitalier Universitaire Angers; and Institut MITOVASC, CNRS UMR 6215, INSERM U1083, Angers University, Angers, France. 9. Medical Centre Leeuwarden, Department of Intensive Care, Leeuwarden, the Netherlands. 10. Department of Anesthesia and Intensive Care, IRCCS Humanitas Research Hospital, Via Manzoni 56, Milan, Italy. 11. Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, Milan, Italy. 12. Department of Anaesthesiology and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden. 13. Department of Anaesthesiology & Intensive Care Medicine, AP-HP, Hôpital Européen Georges Pompidou, Paris, France. 14. Université de Paris, Paris, France. 15. Section of Anaesthesiology and Intensive Care, Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden. 16. Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium. 17. Cátedra de Farmacología Aplicada, Facultad de Ciencias Médicas, Universidad Nacional de La Plata Y Servicio de Terapia Intensiva, Sanatorio Otamendi, Buenos Aires, Argentina. 18. Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University Linz, Linz, Austria. 19. Department of Anaesthesia and Intensive Care, Assistance Publique Des Hopitaux de Paris, Hôpitaux Universitaires Paris-Saclay, Université Paris-Saclay, Hôpital de Bicêtre, Le Kremlin-Bicêtre, France. 20. Division of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, London, UK. 21. Department of Cardiopneumology, Instituto Do Coracao, Universidade de São Paulo, Hospital SirioLibanes, São Paulo, Brazil. 22. Assistance Publique-Hôpitaux de Paris, Paris Saclay University Hospitals, Antoine Béclère Hospital, Paris, France. 23. Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile. 24. Servicio de Terapia Intensiva, Hospital Fernández, Buenos Aires, Argentina. 25. Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands. 26. Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy. 27. Aix Marseille Université, Assistance Publique Hôpitaux de Marseille, Service D'Anesthésie Et de Réanimation CHU Nord, Marseille, France. 28. Service de Réanimation Médicale Brabois Et Pôle Cardio-Médico-Chirurgical. CHRU Brabois, INSERM U1116, Université de Lorraine, Vandoeuvre les NancyNancy, 54500, France. 29. Department of Anesthesia, Burn and Critical Care, APHP Hôpitaux Universitaires Saint Louis LariboisièreUniversité Paris DiderotU942 Inserm, Paris, France. 30. Medical Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, Paris-Saclay University Hospitals, Bicêtre hospital, Le Kremlin-Bicêtre, France. 31. INSERM UMR_S 999, FHU SEPSIS, Le Kremlin-Bicêtre, France. 32. Department of Clinical Internal, Anesthesiological and Cardiovascular Science, Sapienza University of Rome, Rome, Italy. 33. University Paris 7 Denis Diderot; INSERM 1160 and Hôpital Lariboisière, APHP, Paris, France. 34. William Harvey Research Institute, Queen Mary University of London, London, EC1M 6BQ, UK. 35. Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, USA. 36. Institut Für Anästhesiologische Pathophysiologie Und Verfahrensentwicklung, Universitätsklinikum Ulm, Ulm, Germany. 37. Department of Anesthesiology and Intensive Care Medicine, Rostock University Medical Centre, Rostock, Germany. 38. Department of Anesthesiology and Intensive Care, Uniklinikum Jena, Jena, Germany. 39. Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Giessen, UKGM, Justus-Liebig University Giessen, Giessen, Germany. 40. Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany. 41. Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, London, UK. 42. ICU Department, Réanimation CERIC, Clinique Ambroise Paré, Neuilly, France. 43. Assistance Publique-Hôpitaux de Paris, University Hospital Ambroise Paré, intensive care unit, Boulogne-Billancourt, France. 44. INSERM U-1018, CESP, Team 5, University of Versailles Saint-Quentin en Yvelines, Villejuif, France. 45. Medical-Surgical Intensive Care Unit, INSERM CIC-1435, Teaching Hospital of Limoges, Limoges, France. 46. University of Limoges, Limoges, France. 47. Université Libre de Bruxelles - Dept of Intensive Care, Erasme Univ Hospital, Brussels, Belgium. 48. Department of Intensive Care Medicine, Maastricht University Medical Center, Maastricht, The Netherlands. 49. Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark. 50. Department of Anesthesia and Intensive Care, Aarhus University Hospital, Aarhus, Denmark.
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.
BACKGROUND: Treatment decisions on critically illpatients 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 illpatients 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 illpatients 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.
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