Current use of inotropes in circulatory shock

Thomas W L Scheeren¹, Jan Bakker^{2

3

4

5}, Thomas Kaufmann⁶, Djillali Annane⁷, Pierre Asfar⁸, E Christiaan Boerma⁹, Maurizio Cecconi^{10

11}, Michelle S Chew¹², Bernard Cholley^{13

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 Monnet^{30

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-Baron^{43

44}, Philippe Vignon^{45

46}, Jean-Louis Vincent⁴⁷, Iwan C C van der Horst⁴⁸, Simon T Vistisen^{49

50}, Jean-Louis Teboul^{30

31}

Affiliations

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.

PMID: 33512597
PMCID: PMC7846624
DOI: 10.1186/s13613-021-00806-8

Current use of inotropes in circulatory shock

Thomas W L Scheeren et al. Ann Intensive Care. 2021.

. 2021 Jan 29;11(1):21.

doi: 10.1186/s13613-021-00806-8.

Authors

Affiliations

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.

PMID: 33512597
PMCID: PMC7846624
DOI: 10.1186/s13613-021-00806-8

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.

Keywords: Acute circulatory failure; Cardiac output; Cardiogenic shock; Catecholamines; Inotropes; Levosimendan; PDE-inhibitors; Resuscitation; Sepsis; Septic shock; Vasoactive agents.

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Conflict of interest statement

A.M. received speaker’s honoraria from Novartis, Orion, and Servier and fees as a member of the advisory board or steering committee from Adrenomed, Sanofi, Roche, Abbott, and 4TEEN4. The other authors have no competing interest to declare regarding this paper.

Figures

**Fig. 1**
Expert answers to the first questionnaire and level of agreement. Answers are visualized as percentages. Positive answers are presented in green, conditional answers are presented in yellow, negative answers are presented in red. *PDE* phosphodiesterase, *v-a PCO*₂ veno-arterial PCO₂ difference, *GoR* grade of recommendation

See this image and copyright information in PMC

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Current use of inotropes in circulatory shock

Affiliations

Current use of inotropes in circulatory shock

Authors

Affiliations

Abstract

Conflict of interest statement

Figures

References

Grants and funding

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Full Text Sources

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Miscellaneous