Peripheral Metaraminol Infusion in The
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Best evidence topic reports Emerg Med J: first published as 10.1136/emermed-2017-206590.3 on 23 February 2017. Downloaded from THREE-PART QUESTION SEARCH OUTCOMES In (adult patients presenting to the ED with MEDLINE search produced 35 papers. sepsis resulting in persistent hypotension EMBASE search produced 5 papers. not responding to fluid replacement) is CINAHL search produced 4 papers. a (peripheral metaraminol infusion as ProQuest search produced 55 papers. effective as central catecholamine infusion) PubMed search produced 150 papers. Cochrane database revealed one article of for (maintaining a blood pressure capable interest, but I was unable to obtain bar a of effective organ perfusion)? worldwide search and translation. NICE Evidence search identified no additional CLINICAL SCENARIO relevant articles. A previously fit and well 36-year-old male College of Emergency Medicine website returns from a holiday to Greece 48 hours contained no relevant evidence or guide- ago and presents to the ED complaining lines. The Australian, American, Canadian of headache, malaise and feeling generally and New Zealand colleges of emergency unwell. While waiting to be seen, the medicine were searched but contained no patient’s headache rapidly worsens, he relevant evidence or guidelines. spikes a high temperature of 38.9°C, Citations from articles of interest were becomes increasingly agitated and starts also searched and revealed several new vomiting. He is taken to a resuscitation articles which appeared relevant to the cubicle and has a HR of 135 bpm and three-part question. However, these BP of 71/45 mm Hg. Examination of the were all predated publications from 1964. patient reveals several small non-blanching For most articles, I was unable to obtain petechiae. You manage the patient as an abstract, the abstract was in a foreign suspected meningitis and commence language and I was unable to obtain appropriate sepsis management. After any articles in full via internet or library administrating 3 L of intravenous fluid, searches. the patient remains with a systolic BP In total, eight articles were identified <80 mm Hg. The intensive care doctor that were relevant to the three-part ques- informs you that they are trying to make a tion (table 3). space available in the intensive treatment unit for this patient but are struggling to COMMENTS step anyone down and the patient must Natalini et al specifically focused on remain in the resuscitation department. the comparison of noradrenaline and The resuscitation nurse asks you to metaraminol as a vasopressor for the prescribe more fluid. You wonder whether management of septic shock and revealed a peripheral metaraminol infusion would that there was no significant difference in be more effective at increasing arterial patient’s cardiac output, haemodynamic http://emj.bmj.com/ pressure and maintaining organ perfusion. variables or acid–base status. They also BET 3: PERIPHERAL METARAMINOL found that there was no relationship in INFUSION IN THE EMERGENCY the doses provided to achieve patient DEPARTMENT SEARCH STRATEGY optimisation. Hou et al demonstrated Ovid MEDLINE (1946 to present). that metaraminol infusion caused no Authors: Kenneth Anderson, Hridesh Chatha EMBASE (1974 to present) statistical difference to renal function over Affiliation: Stepping Hill Hospital, CINAHL (1981 to present) time regardless of the infusion strength. on September 24, 2021 by guest. Protected copyright. Stockport NHS Trust, Stockport, Manchester, UK ProQuest Database Makowski et al conducted a small study Pubmed Database which demonstrated that metaraminol can ABSTRACT Cochrane Database be given to good effect peripherally and A short cut review was carried out to NICE Evidence Database potentially be used for long periods of time. establish whether peripheral metaraminol The remaining studies demonstrated that College of Emergency Medicine infusions can be safely and effectively used metaraminol was an effective treatment A grey literature search was performed in emergency department patients. 239 for managing shock when compared with papers were found of which 8 presented via www. google. com, www. opengrey. eu other vasopressor therapies, both in terms the best evidence to answer the clinical and www. controlled- trials. com of drug efficacy and patient mortality. All question. The author, date and country ([ metaraminol. mp or exp metaraminol] of the studies were small retrospective of publication, patient group studied, OR [ aramine. mp or exp aramine] OR [ or prospective cohort studies, with one study type, relevant outcomes, results and levicor. mp] AND [ noradrenaline. mp or small crossover trial, at which the level study weaknesses of these best papers are exp norepinephrine] OR [ adrenaline. mp of evidence was not very strong. One tabulated. The clinical bottom line is that or exp epinephrine] AND [ sepsis. mp or of the studies was identified as a poster despite anecdotal evidence of common sepsis] OR [ hypotension. mp or hypoten- presentation at an International anaesthetic usage there is limited high quality sion]). conference had only ever been published evidence to support the use of peripheral The references and citations of review in abstract form, making appraisal of the metaraminol as vasopressor support in the articles were also searched for articles rel- study findings impossible. All the papers emergency department. evant to the three-part question. had low numbers of patients, there were no 190 Emerg Med J March 2017 Vol 34 No 3 Best evidence topic reports Emerg Med J Table 3 Relevant papers Author, year, country of Study type (level of March 2017 Vol 34No3 Vol March 2017 publication Patient group evidence) Outcomes Key results Study weaknesses Natalini et al 10 patients admitted to a single Italian medical and surgical Prospective cohort 1. Detection of cardiac 1. No significant difference demonstrated in stroke No randomisation of study drugs. No 2005,1 intensive care unit who met following inclusion criteria: (1) study (level 2b) output >30% volume index (mL/beats/m²) norepinephrine (40±15) blinding of physicians or patients (although Italy diagnosis of septic shock, (2) adequate fluid resuscitation and metaraminol (40±15) (p=0.991) and HR (beats/min) does state that this was considered pulmonary artery occlusion pressure >14 mm Hg, (3) use of norepinephrine (96±15) metaraminol (95±21) (p=0.863) unethical for the patient group being norepinephrine to maintain MAP >65 mm Hg. Norepinephrine 2. Haemodynamic 2. No significant difference demonstrated in global studied). Small patient numbers and metaraminol variables haemodynamic variables 3. Drug doses 3. No relationship between norepinephrine (0.30±0.28 µg/kg/min) and metaraminol (2.5±1.7 µg/kg/min) doses (R²=0.087) 4. Patient acid–base 4. No difference in acid–base status between status norepinephrine (− 4.2/−3.9) and M (−4.2/−3.8) (p=0.919) Hou et al, Single centre study. 98 patients with septic shock (using Retrospective cohort. 1. Apache III 2. Urine out- No statistical significant differences in the changes No power calculation. No control group. 2007,2 Hurford’s diagnostic criteria) were divided into three groups Observational study put (mL/hour) of these renal function parameters with time among Unclear inclusion/exclusion criteria. Retro- China (A, B, C) according to highest infusion rate of metaraminol (level 2b) 3. U-ALB (mg/L) 4. Uβ2- the three groups spective reporting bias used (0.1–0.5, 0.6–1.0, >1.0 µg/kg), respectively MG (mg/L) 5. BUN (mmol/L) 6. CRE (µmol/L) Makowski and 47 patients (25 female, 22 male) admitted to single- centred Prospective 1. Reason for starting 1. Sepsis 34%, others 66% Abstract only. Poster presentation at Misztal, surgical HDU who were started on peripheral metaraminol observational metaraminol the Lisbon International Anaesthesia 3 2010, infusion study (level 3) 2. Average infusion time 2. 37.62 hours (range 1.5–144 hours) Conference 2012. Small patient numbers UK 3. Central line insertion 3. CVCs inserted in 36% of patients (%) 4. Fluid balance (before/ 4. 12 hours before infusion 2570.64±1198.01 mls after metaraminol infusion) 12 hours after infusion 985±377.61 mls (p=0.0001) (mean±SD) Udhoji et al, 12 patients with hypotension and clinical features of Prospective 1. Cardiac index 1. Cardiac indexes were lower in all cases during Old publication—less generalisable. Small 1964,4 shock from varying aetiology. Levarterenol (noradrenaline, crossover study infusion of angiotensin vs levarterenol (1.7 vs patient numbers (no power calculation). USA norepinephrine) (level 2b) 2.0 L/min/sq m) (p<0.01) or metaraminol (1.8 vs 2.8 L/ No blinding. No description of randomi- Metaraminol or angiotensin were administered by intravenous min/sq m) (p, 0.01) sation technique. Urine flow data difficult infusion 2. Urine flow 2. In 10 of 12 patients urine flow was significantly to interpret. No washout period between Six patients received angiotensin first followed by levarterenol reduced during angiotensin infusion compared with different drugs. No attempt to exclude or metaraminol. The other six patients received levarterenol or metaraminol or levarterenol. confounding factors metaraminol followed by angiotensin Mills et al, 67 patients with shock from varying aetiology were given one Prospective cohort 1. Shock due to MI 1. 20 patients. 13 survived. Survival rate in those with Old publication—less generalisable. No 1960,5 or combination of mephentermine, metaraminol, phenyle- observation study metaraminol exceeded previously reported with use of description of inclusion criteria. Unclear USA phrine, levarterenol, epinephrine and methoxamine. Patients (level 3) levarterenol methodology as how drugs were given, for were selected at random and treated by resident staff and 2. Shock due to sepsis 2. Nine patients. One survived, three had satisfactory how long, in which combination. Results faculty response to vasopressor therapy and were normotensive section confusing as it lists results from at death various other studies (both animal and 3. Shock due to 3. Seven patients. Two survived. All those who failed human trials).