Pub Date : 2025-02-05DOI: 10.1016/j.bjane.2025.844596
Luciana C. Stefani , Liana M.T.A. Azi , Andre P. Schmidt
{"title":"Transforming perioperative care in Brazil: challenges and opportunities for improving outcomes","authors":"Luciana C. Stefani , Liana M.T.A. Azi , Andre P. Schmidt","doi":"10.1016/j.bjane.2025.844596","DOIUrl":"10.1016/j.bjane.2025.844596","url":null,"abstract":"","PeriodicalId":32356,"journal":{"name":"Brazilian Journal of Anesthesiology","volume":"75 2","pages":"Article 844596"},"PeriodicalIF":1.7,"publicationDate":"2025-02-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143375056","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-01-26DOI: 10.1016/j.bjane.2025.844595
Simone Chaves Fagondes , Carmem Lúcia Oliveira da Silva , Anneliese Hoffmann , Rita de Cássia Guedes de Azevedo Barbosa , Daiane Falkembach , Ângela Beatriz John
Growing evidence of the benefits of home ventilatory support in patients with chronic respiratory failure along with technological advances in ventilators have enabled their use in overly complex situations, shaping a new scenario for physicians. This has further given rise to new challenges related to their incorporation into current medical practice. However, this evolution needs to be coupled with knowledge and skills of physicians who are willing to prescribe Home Mechanical Ventilation (HMV), in order to prevent them from making inappropriate choices or adjustments that may ultimately have ethical and legal implications. This article aims to provide guidance and information to support the indication for HMV and the ventilation modalities to be implemented, review basic ventilation concepts, including the ventilator modes most commonly used in patients outside the hospital setting, list the brands and models available in the Brazilian market, provide the means for obtaining equipment for HMV, and finally, describe the requirements for selection of equipment, taking into account the individual characteristics of the patient to ensure safe perioperative care and earlier dehospitalization.
{"title":"Home mechanical ventilation: a narrative review and a proposal of practical approach","authors":"Simone Chaves Fagondes , Carmem Lúcia Oliveira da Silva , Anneliese Hoffmann , Rita de Cássia Guedes de Azevedo Barbosa , Daiane Falkembach , Ângela Beatriz John","doi":"10.1016/j.bjane.2025.844595","DOIUrl":"10.1016/j.bjane.2025.844595","url":null,"abstract":"<div><div>Growing evidence of the benefits of home ventilatory support in patients with chronic respiratory failure along with technological advances in ventilators have enabled their use in overly complex situations, shaping a new scenario for physicians. This has further given rise to new challenges related to their incorporation into current medical practice. However, this evolution needs to be coupled with knowledge and skills of physicians who are willing to prescribe Home Mechanical Ventilation (HMV), in order to prevent them from making inappropriate choices or adjustments that may ultimately have ethical and legal implications. This article aims to provide guidance and information to support the indication for HMV and the ventilation modalities to be implemented, review basic ventilation concepts, including the ventilator modes most commonly used in patients outside the hospital setting, list the brands and models available in the Brazilian market, provide the means for obtaining equipment for HMV, and finally, describe the requirements for selection of equipment, taking into account the individual characteristics of the patient to ensure safe perioperative care and earlier dehospitalization.</div></div>","PeriodicalId":32356,"journal":{"name":"Brazilian Journal of Anesthesiology","volume":"75 3","pages":"Article 844595"},"PeriodicalIF":1.7,"publicationDate":"2025-01-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143054410","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Extracorporeal Cardiopulmonary Resuscitation (ECPR) is an effective intervention for restoring adequate circulatory perfusion after cardiac arrest. Ensuring high-quality Cardiopulmonary Resuscitation (CPR) before initiating Extracorporeal Membrane Oxygenation (ECMO) is critical to mitigate tissue hypoxia and ischemia. This study aimed to evaluate the effect of End-Tidal Carbon Dioxide (ETCO2) Goal-Directed CPR (GDCPR) on neurological function before ECMO using a retrospective case-control analysis.
Methods
The medical records of all patients who received ECPR treated at Zhongshan City People's Hospital were collected between January 2020 and March 2023. In this retrospective cohort study, the patients were divided into Conventional CPR (CCPR) and ETCO2-GDCPR groups based on whether ETCO2 was used as a guide for CPR.
Results
A total of 71 patients were included, of whom 46 comprised the CCPR group and 25 comprised the GDCPR group. Approximately 37% of patients who received ECPR had good cerebral function at discharge, with a higher rate in the GDCPR group (52%) compared with the CCPR group (28%) (p = 0.047). Multivariate analysis showed that the Highest Interleukin-6 (H-IL6) levels after ECMO (Odds Ratio [OR = 1.001], 95% Confidence Interval [95% CI 1.000–1.003], p = 0.005) was a risk factor for neurological function at discharge. The other risk factors for poor prognosis in patients who received ECPR included pre-ECMO CPR protocols (OR = 10.74, 95% CI 1.90–60.48, p = 0.007) and IL6 levels after ECMO (OR = 1.002, 95% CI 1.001–1.003, p = 0.005). ECMO duration (OR = 0.83, 95% CI 0.74–0.94, p = 0.002) was identified as a protective factor. Patients with short ECMO duration have a poor prognosis. The area under the curve for ECMO duration was 0.86 (0.77–0.94, p < 0.01), while that for H-IL6 was 0.19 (0.09–0.29, p < 0.01).
Conclusion
ETCO2-guided ECPR is associated with improved neurological prognosis and patient outcomes. Therefore, monitoring ETCO2 levels should be considered a crucial component of evaluating resuscitation efficacy during CPR.
背景：体外心肺复苏（ECPR）是心脏骤停后恢复充足循环灌注的有效干预措施。在启动体外膜氧合（ECMO）之前确保高质量的心肺复苏（CPR）对于减轻组织缺氧和缺血至关重要。本研究旨在通过回顾性病例对照分析，评估潮末二氧化碳（ETCO2）目标导向CPR （GDCPR）对ECMO前神经功能的影响。方法：收集2020年1月至2023年3月在中山市人民医院接受ECPR治疗的所有患者病历。在本回顾性队列研究中，根据是否使用ETCO2作为CPR指导，将患者分为常规CPR （Conventional CPR， CCPR）组和ETCO2- gdcpr组。结果：共纳入71例患者，其中CCPR组46例，GDCPR组25例。约37%接受ECPR的患者出院时脑功能良好，GDCPR组（52%）高于CCPR组（28%）（p = 0.047）。多因素分析显示，ECMO后最高的白细胞介素-6 （H-IL6）水平（优势比[OR = 1.001]，95%可信区间[95% CI 1.000-1.003], p = 0.005）是出院时神经功能的危险因素。接受ECPR患者预后不良的其他危险因素包括ECMO前CPR方案（OR=10.74, 95% CI 1.90-60.48, p = 0.007）和ECMO后il -6水平（OR = 1.002,95% CI 1.001-1.003, p = 0.005）。ECMO持续时间（OR = 0.83,95% CI 0.74-0.94, p = 0.002）被确定为保护因素。ECMO持续时间短的患者预后较差。ECMO持续时间曲线下面积为0.86 (0.77 ~ 0.94,p < 0.01)， H-IL6曲线下面积为0.19 （0.09 ~ 0.29,p < 0.01）。结论：etco2引导下的ECPR可改善神经系统预后和患者预后。因此，监测ETCO2水平应被视为评估心肺复苏术中复苏效果的重要组成部分。
{"title":"End-tidal carbon dioxide-guided extracorporeal cardiopulmonary resuscitation improves neurological prognosis in patients: a single-center retrospective cohort study","authors":"Xiaozu Liao, Chen Gu, Zhou Cheng, Kepeng Liu, Qing Yin, Binfei Li","doi":"10.1016/j.bjane.2025.844588","DOIUrl":"10.1016/j.bjane.2025.844588","url":null,"abstract":"<div><h3>Background</h3><div>Extracorporeal Cardiopulmonary Resuscitation (ECPR) is an effective intervention for restoring adequate circulatory perfusion after cardiac arrest. Ensuring high-quality Cardiopulmonary Resuscitation (CPR) before initiating Extracorporeal Membrane Oxygenation (ECMO) is critical to mitigate tissue hypoxia and ischemia. This study aimed to evaluate the effect of End-Tidal Carbon Dioxide (ETCO<sub>2</sub>) Goal-Directed CPR (GDCPR) on neurological function before ECMO using a retrospective case-control analysis.</div></div><div><h3>Methods</h3><div>The medical records of all patients who received ECPR treated at Zhongshan City People's Hospital were collected between January 2020 and March 2023. In this retrospective cohort study, the patients were divided into Conventional CPR (CCPR) and ETCO<sub>2</sub>-GDCPR groups based on whether ETCO<sub>2</sub> was used as a guide for CPR.</div></div><div><h3>Results</h3><div>A total of 71 patients were included, of whom 46 comprised the CCPR group and 25 comprised the GDCPR group. Approximately 37% of patients who received ECPR had good cerebral function at discharge, with a higher rate in the GDCPR group (52%) compared with the CCPR group (28%) (p = 0.047). Multivariate analysis showed that the Highest Interleukin-6 (H-IL6) levels after ECMO (Odds Ratio [OR = 1.001], 95% Confidence Interval [95% CI 1.000–1.003], p = 0.005) was a risk factor for neurological function at discharge. The other risk factors for poor prognosis in patients who received ECPR included pre-ECMO CPR protocols (OR = 10.74, 95% CI 1.90–60.48, p = 0.007) and IL6 levels after ECMO (OR = 1.002, 95% CI 1.001–1.003, p = 0.005). ECMO duration (OR = 0.83, 95% CI 0.74–0.94, p = 0.002) was identified as a protective factor. Patients with short ECMO duration have a poor prognosis. The area under the curve for ECMO duration was 0.86 (0.77–0.94, p < 0.01), while that for H-IL6 was 0.19 (0.09–0.29, p < 0.01).</div></div><div><h3>Conclusion</h3><div>ETCO<sub>2</sub>-guided ECPR is associated with improved neurological prognosis and patient outcomes. Therefore, monitoring ETCO<sub>2</sub> levels should be considered a crucial component of evaluating resuscitation efficacy during CPR.</div></div>","PeriodicalId":32356,"journal":{"name":"Brazilian Journal of Anesthesiology","volume":"75 3","pages":"Article 844588"},"PeriodicalIF":1.7,"publicationDate":"2025-01-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143042757","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-01-22DOI: 10.1016/j.bjane.2025.844589
Jacek B. Cywinski , Yufei Li , Lusine Israelyan , Roshni Sreedharan , Silvia Perez-Protto , Kamal Maheshwari
Background
Extreme hemodynamic changes, especially intraoperative hypotension (IOH), are common and often prolonged during Liver Transplant (LT) surgery and during initial hours of recovery. Hypotension Prediction Index (HPI) software is one of the tools which can help in proactive hemodynamic management. The accuracy of the advanced hemodynamic parameters such as Cardiac Output (CO) and Systemic Vascular Resistance (SVR) obtained from HPI software and prediction performance of the HPI in LT surgery remains unknown.
Methods
This was a retrospective observational study conducted in a tertiary academic center with a large liver transplant program. We enrolled 23 adult LT patients who received both Pulmonary Artery Catheter (PAC) and HPI software monitoring. Primarily, we evaluated agreement between PAC and HPI software measured CO and SVR. A priori, we defined a relative difference of less than 20% between measurements as an adequate agreement for a pair of measurements and estimated the Lin's Concordance Correlation Coefficient and Bland-Altman Limits of Agreement (LOA). Clinically acceptable LOA was defined as ± 1 L.min-1 for CO and ± 200 dynes s.cm-5 for SVR. Secondary outcome was the ability of the HPI to predict future hypotension, defined as Mean Arterial Pressure (MAP) less than 65 mmHg lasting at least one minute. We estimated sensitivity, positive predictive value, and time from alert to hypotensive events for HPI software.
Results
Overall, 125 pairs of CO and 122 pairs of SVR records were obtained from 23 patients. Based on our predefined criteria, only 42% (95% CI 30%, 55%) of CO records and 53% (95% CI 28%, 72%) of SVR records from HPI software were considered to agree with those from PAC. Across all patients, there were a total of 1860 HPI alerts (HPI ≥ 85) and 642 hypotensive events (MAP < 65 mmHg). Out of the 642 hypotensive events, 618 events were predicted by HPI alert with sensitivity of 0.96 (95% CI: 0.95). Many times, the HPI value remained above alert level and was followed by multiple hypotensive events. Thus, to evaluate PPV and time to hypotension metric, we considered only the first HPI alert followed by a hypotensive event (“true alerts”). The “true alert” was the first alert when there were several alerts before a hypotension. There were 614 “true alerts” and the PPV for HPI was 0.33 (95% CI 0.31, 0.35). The median time from HPI alert to hypotension was 3.3 [Q1, Q3: 1, 9.3] mins.
Conclusion
There was poor agreement between the pulmonary artery catheter and HPI software calculated advanced hemodynamic parameters (CO and SVR), in the patients undergoing LT surgery. HPI software had high sensitivity but poor specificity for hypotension prediction, resulting in a high burden of false alarms.
背景：极端的血流动力学变化，特别是术中低血压（IOH），在肝移植（LT）手术和恢复的最初几个小时内是常见的，并且经常延长。低血压预测指数（HPI）软件是主动进行血流动力学管理的工具之一。HPI软件获得的心输出量（CO）和全身血管阻力（SVR）等高级血流动力学参数的准确性以及HPI在LT手术中的预测性能尚不清楚。方法：这是一项回顾性观察性研究，在一个大型肝移植项目的三级学术中心进行。我们招募了23名接受肺动脉导管（PAC）和HPI软件监测的成年LT患者。首先，我们评估了PAC和HPI软件测量CO和SVR之间的一致性。先验地，我们将测量值之间的相对差异小于20%定义为一对测量值的足够一致性，并估计了Lin’s一致性相关系数和Bland-Altman一致性极限（LOA）。临床上可接受的LOA定义为CO为±1 L.min-1， SVR为±200 dynes s.cm-5。次要结果是HPI预测未来低血压的能力，定义为平均动脉压（MAP）低于65 mmHg持续至少一分钟。我们估计了HPI软件的敏感性、阳性预测值和从警报到低血压事件的时间。结果：23例患者共获得125对CO和122对SVR记录。根据我们的预定义标准，HPI软件中只有42% （95% CI 30%, 55%）的CO记录和53% （95% CI 28%, 72%）的SVR记录被认为与PAC的记录一致。在所有患者中，共有1860次HPI警报（HPI≥85）和642次低血压事件（MAP< 65 mmHg）。在642例低血压事件中，HPI预警预测618例事件，敏感性为0.96 （95% CI: 0.95）。许多时候，HPI值保持在警戒水平以上，随后发生多次低血压事件。因此，为了评估PPV和降压时间指标，我们只考虑了第一次HPI警报之后的低血压事件（“真实警报”）。“真正的警报”是在低血压之前有几个警报时的第一个警报。有614例“真实警报”，HPI的PPV为0.33 （95% CI 0.31, 0.35）。从HPI警报到低血压的中位时间为3.3分钟[Q1， Q3: 1,9.3]分钟。结论：在接受LT手术的患者中，肺动脉导管与HPI软件计算的晚期血流动力学参数（CO和SVR）之间的一致性较差。HPI软件对低血压的预测敏感性高，但特异性差，导致虚警负担高。
{"title":"Evaluation of hypotension prediction index software in patients undergoing orthotopic liver transplantation: retrospective observational study","authors":"Jacek B. Cywinski , Yufei Li , Lusine Israelyan , Roshni Sreedharan , Silvia Perez-Protto , Kamal Maheshwari","doi":"10.1016/j.bjane.2025.844589","DOIUrl":"10.1016/j.bjane.2025.844589","url":null,"abstract":"<div><h3>Background</h3><div>Extreme hemodynamic changes, especially intraoperative hypotension (IOH), are common and often prolonged during Liver Transplant (LT) surgery and during initial hours of recovery. Hypotension Prediction Index (HPI) software is one of the tools which can help in proactive hemodynamic management. The accuracy of the advanced hemodynamic parameters such as Cardiac Output (CO) and Systemic Vascular Resistance (SVR) obtained from HPI software and prediction performance of the HPI in LT surgery remains unknown.</div></div><div><h3>Methods</h3><div>This was a retrospective observational study conducted in a tertiary academic center with a large liver transplant program. We enrolled 23 adult LT patients who received both Pulmonary Artery Catheter (PAC) and HPI software monitoring. Primarily, we evaluated agreement between PAC and HPI software measured CO and SVR. A priori, we defined a relative difference of less than 20% between measurements as an adequate agreement for a pair of measurements and estimated the Lin's Concordance Correlation Coefficient and Bland-Altman Limits of Agreement (LOA). Clinically acceptable LOA was defined as ± 1 L.min<sup>-1</sup> for CO and ± 200 dynes s.cm<sup>-5</sup> for SVR. Secondary outcome was the ability of the HPI to predict future hypotension, defined as Mean Arterial Pressure (MAP) less than 65 mmHg lasting at least one minute. We estimated sensitivity, positive predictive value, and time from alert to hypotensive events for HPI software.</div></div><div><h3>Results</h3><div>Overall, 125 pairs of CO and 122 pairs of SVR records were obtained from 23 patients. Based on our predefined criteria, only 42% (95% CI 30%, 55%) of CO records and 53% (95% CI 28%, 72%) of SVR records from HPI software were considered to agree with those from PAC. Across all patients, there were a total of 1860 HPI alerts (HPI ≥ 85) and 642 hypotensive events (MAP < 65 mmHg). Out of the 642 hypotensive events, 618 events were predicted by HPI alert with sensitivity of 0.96 (95% CI: 0.95). Many times, the HPI value remained above alert level and was followed by multiple hypotensive events. Thus, to evaluate PPV and time to hypotension metric, we considered only the first HPI alert followed by a hypotensive event (“true alerts”). The “true alert” was the first alert when there were several alerts before a hypotension. There were 614 “true alerts” and the PPV for HPI was 0.33 (95% CI 0.31, 0.35). The median time from HPI alert to hypotension was 3.3 [Q1, Q3: 1, 9.3] mins.</div></div><div><h3>Conclusion</h3><div>There was poor agreement between the pulmonary artery catheter and HPI software calculated advanced hemodynamic parameters (CO and SVR), in the patients undergoing LT surgery. HPI software had high sensitivity but poor specificity for hypotension prediction, resulting in a high burden of false alarms.</div></div>","PeriodicalId":32356,"journal":{"name":"Brazilian Journal of Anesthesiology","volume":"75 3","pages":"Article 844589"},"PeriodicalIF":1.7,"publicationDate":"2025-01-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143043236","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-01-14DOI: 10.1016/j.bjane.2025.844586
Andre P. Schmidt , Federico Bilotta
{"title":"Challenges in surgical and perioperative care for Brazil's aging population","authors":"Andre P. Schmidt , Federico Bilotta","doi":"10.1016/j.bjane.2025.844586","DOIUrl":"10.1016/j.bjane.2025.844586","url":null,"abstract":"","PeriodicalId":32356,"journal":{"name":"Brazilian Journal of Anesthesiology","volume":"75 2","pages":"Article 844586"},"PeriodicalIF":1.7,"publicationDate":"2025-01-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11761882/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143017382","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-01-14DOI: 10.1016/j.bjane.2025.844587
Andre P. Schmidt , Clovis T. Bevilacqua Filho , Eduarda S. Martinelli , Virgínia C. de Moura
{"title":"The pulmonary artery catheter in modern anesthesiology and intensive care: indications, benefits, and limitations","authors":"Andre P. Schmidt , Clovis T. Bevilacqua Filho , Eduarda S. Martinelli , Virgínia C. de Moura","doi":"10.1016/j.bjane.2025.844587","DOIUrl":"10.1016/j.bjane.2025.844587","url":null,"abstract":"","PeriodicalId":32356,"journal":{"name":"Brazilian Journal of Anesthesiology","volume":"75 2","pages":"Article 844587"},"PeriodicalIF":1.7,"publicationDate":"2025-01-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143017384","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-01-03DOI: 10.1016/j.bjane.2024.844584
Stefania Lacerda Garcia , Claudia Marquez Simões , Maria José Carvalho Carmona , Liana Maria Tôrres de Araújo Azi
{"title":"Gender representation in anesthesiology research: a historical perspective from the Brazilian Journal of Anesthesiology","authors":"Stefania Lacerda Garcia , Claudia Marquez Simões , Maria José Carvalho Carmona , Liana Maria Tôrres de Araújo Azi","doi":"10.1016/j.bjane.2024.844584","DOIUrl":"10.1016/j.bjane.2024.844584","url":null,"abstract":"","PeriodicalId":32356,"journal":{"name":"Brazilian Journal of Anesthesiology","volume":"75 2","pages":"Article 844584"},"PeriodicalIF":1.7,"publicationDate":"2025-01-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142928759","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-01-01DOI: 10.1016/j.bjane.2024.844580
Ka Ting Ng , Pei En Kwok , Wei En Lim , Wan Yi Teoh , Mohd Shahnaz Hasan , Mohd Fitry Zainal Abidin
Objectives
Methylene blue exerts its vasopressor properties by inhibiting nitric oxide-mediated vasodilation. Recent studies have advocated the use of methylene blue as a rescue therapy for patients with septic shock. The primary aim was to investigate the effect of methylene blue on the mean arterial pressure among adult patients with septic shock.
Methods
Databases of MEDLINE, EMBASE, and CENTRAL were searched from their inception date until October 2023. Randomized Clinical Trials (RCT) comparing methylene blue and placebo in adults with septic shock were included.
Results
Our systematic review included 5 studies (n = 257) for data analysis. As compared to the placebo, our pooled analysis showed that methylene blue significantly increased mean arterial pressure (MD: 1.34 mmHg, 95% CI 0.15 to 2.53, p = 0.03, level of evidence: very low). Patients who were given methylene blue were associated with statistically lower mortality rate (OR = 0.49, 95% CI 0.27 to 0.88, p = 0.02, level of evidence: low), reduced serum lactate levels (MD: -0.76 mmoL.L-1, 95% CI -1.22 to -0.31, p = 0.0009, level of evidence: low), reduced length of hospital stay (MD: -1.94 days, 95% CI -3.79 to -0.08, p = 0.04, level of evidence: low), and increased PaO2/FiO2 (MD: 34.78, 95% CI 8.94 to 60.61, p = 0.008, level of evidence: low).
Conclusions
This meta-analysis demonstrated that methylene blue administration was associated with an increased in mean arterial pressure and PaO2/FiO2 ratio, along with a reduction in mortality rates, serum lactate levels, and length of hospital stay. However, substantial degree of heterogeneity and inadequate number of studies with low level of evidence warrant future adequately powered RCTs to affirm our results.
目的：亚甲基蓝通过抑制一氧化氮介导的血管舒张发挥其血管加压特性。最近的研究提倡使用亚甲基蓝作为脓毒性休克患者的抢救治疗。主要目的是研究亚甲基蓝对脓毒性休克成年患者平均动脉压的影响。方法：检索MEDLINE、EMBASE和CENTRAL数据库，检索时间为建站日期至2023年10月。随机临床试验（RCT）比较亚甲基蓝和安慰剂在成人感染性休克。结果：我们的系统综述纳入了5项研究（n = 257）进行数据分析。与安慰剂相比，我们的合并分析显示亚甲基蓝显著增加了平均动脉压（MD: 1.34 mmHg, 95% CI 0.15至2.53,p = 0.03，证据水平非常低）。给予亚甲基蓝的患者死亡率降低（OR = 0.49,95% CI 0.27 ~ 0.88, p = 0.02，证据水平低），血清乳酸水平降低（MD: -0.76 mmoL）。L-1, 95% CI -1.22 ~ -0.31, p = 0.0009，证据水平低)，住院时间缩短（MD: -1.94天，95% CI -3.79 ~ -0.08, p = 0.04，证据水平低），PaO2/FiO2增加（MD: 34.78, 95% CI 8.94 ~ 60.61, p = 0.008，证据水平低）。结论：该荟萃分析表明，亚甲蓝给药与平均动脉压和PaO2/FiO2比值升高相关，同时降低死亡率、血清乳酸水平和住院时间。然而，大量的异质性和低水平证据的研究数量不足，需要未来足够有力的随机对照试验来证实我们的结果。
{"title":"The use of methylene blue in adult patients with septic shock: a systematic review and meta-analysis","authors":"Ka Ting Ng , Pei En Kwok , Wei En Lim , Wan Yi Teoh , Mohd Shahnaz Hasan , Mohd Fitry Zainal Abidin","doi":"10.1016/j.bjane.2024.844580","DOIUrl":"10.1016/j.bjane.2024.844580","url":null,"abstract":"<div><h3>Objectives</h3><div>Methylene blue exerts its vasopressor properties by inhibiting nitric oxide-mediated vasodilation. Recent studies have advocated the use of methylene blue as a rescue therapy for patients with septic shock. The primary aim was to investigate the effect of methylene blue on the mean arterial pressure among adult patients with septic shock.</div></div><div><h3>Methods</h3><div>Databases of MEDLINE, EMBASE, and CENTRAL were searched from their inception date until October 2023. Randomized Clinical Trials (RCT) comparing methylene blue and placebo in adults with septic shock were included.</div></div><div><h3>Results</h3><div>Our systematic review included 5 studies (n = 257) for data analysis. As compared to the placebo, our pooled analysis showed that methylene blue significantly increased mean arterial pressure (MD: 1.34 mmHg, 95% CI 0.15 to 2.53, p = 0.03, level of evidence: very low). Patients who were given methylene blue were associated with statistically lower mortality rate (OR = 0.49, 95% CI 0.27 to 0.88, p = 0.02, level of evidence: low), reduced serum lactate levels (MD: -0.76 mmoL.L<sup>-1</sup>, 95% CI -1.22 to -0.31, p = 0.0009, level of evidence: low), reduced length of hospital stay (MD: -1.94 days, 95% CI -3.79 to -0.08, p = 0.04, level of evidence: low), and increased PaO<sub>2</sub>/FiO<sub>2</sub> (MD: 34.78, 95% CI 8.94 to 60.61, p = 0.008, level of evidence: low).</div></div><div><h3>Conclusions</h3><div>This meta-analysis demonstrated that methylene blue administration was associated with an increased in mean arterial pressure and PaO<sub>2</sub>/FiO<sub>2</sub> ratio, along with a reduction in mortality rates, serum lactate levels, and length of hospital stay. However, substantial degree of heterogeneity and inadequate number of studies with low level of evidence warrant future adequately powered RCTs to affirm our results.</div></div>","PeriodicalId":32356,"journal":{"name":"Brazilian Journal of Anesthesiology","volume":"75 1","pages":"Article 844580"},"PeriodicalIF":1.7,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11754512/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142775187","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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