LETTER TO THE EDITOR

LETTER TO THE EDITOR

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REFERENCES

Isoproterenol infusion in septic shock Dear Editor, the recent report on “Isoproterenol infusion in septic shock” is very interesting (1). Wiramus et al. concluded that “use of isoproterenol was associated with an increase of tissue oxygen saturation (1).” In fact, there are some issues of isoproterenol use to be discussed. First, the increased heart rate due to infusion is common (2). On the other hand, the occurrence of paradoxical bradycardia can also be observed (3). In addition, the possibility of occurrence of isoproterenol-induced myocardial infarction should be kept in mind (4). The fatal case due to the infusion is reported in the literature (5). To prevent cardiac toxicity due to isoproterenol infusion, careful evaluation before usage is required.

1. Wiramus S, Textoris J, Bardin R, Vigne C, Kelway C, Martin C, et al. Isoproterenol infusion and microcirculation in septic shock. Heart Lung Vessel. 2014; 64: 274-9. 2. Garg M, Khanna D. Exploration of pharmacological interventions to prevent isoproterenol-induced myocardial infarction in experimental models. Ther Adv Cardiovasc Dis. 2014; 8: 155-69. 3. Leone M, Boyadjiev I, Boulos E, Antonini F, Visintini P, Albanèse J, et al. A reappraisal of isoproterenol in goaldirected therapy of septic shock. Shock. 2006; 26: 353-7. 4. Brembilla-Perrot B, Muhanna I, Nippert M, Popovic B, Beurrier D, Houriez P, et al. Paradoxical effect of isoprenaline infusion. Europace. 2005; 7: 621-7. 5. Kurland G, Williams J, Lewiston NJ. Fatal myocardial toxicity during continuous infusion intravenous isoproa63: 407-11.

Viroj Wiwanitkit

Surin Rajabhat University, Surin Thailand Corresponding author: Professor Viroj Wiwanitkit Wiwanitkit House, Bangkhae, Bangkok Thailand 10160 e-mail: [email protected]

Cite this article as: Wiwanitkit V. Isoproterenol infusion in septic shock. Heart, Lung and Vessels. 2015; 7(1): 89. Source of Support: Nil. Conflict of interest: None declared.

RESPONSE No coronary artery occlusion in septic shock: Isoproterenol infusion should not be discouraged Dear Editor, in their relevant letter, Dr Wiwanitkit pointed out important limitations about the use of isoproterenol: these authors should be commended for their input to our research. Indeed, in animal models of coronary occlusion, isoproterenol administration augmented infarct size (1), suggesting that the use of isoproterenol in patients with coronary artery occlusion should be discouraged, probably in favor of the use of dobutamine in the same patients (2). However, in those models, isoproterenol was used as repeated boli of 0.15 mg/kg (i.e. 9 mg for 60 kg) in non-resuscitated animals, whereas in our patients we infused continuously a maximal dosage of 0.5 mg/h after well-conducted resuscitation.

Patients with septic shock do not suffer from coronary occlusion. Several experimental models suggest that septic shock induces an even increased coronary flow (3). In addition, betaadrenoreceptors are desensitized in patients with sepsis (4), supporting the need to introduce the most powerful beta-adrenergic inotrope in selected patients developing a septic acute heart failure (4, 5). Finally, to date, both experimental models and cohorts of patients did not reveal harm associated with the use of isoproterenol in this indication (6, 7). In conclusion, inotropes should be carefully used in few, selected patients. The harmful effect of isoproterenol in animals with coronary occlusion, however, should not discard its potential role in septic shock. REFERENCES 1. Shell WE, Lavelle JF, Covell JW, Sobel BE. Early estimation of myocardial damage in conscious dogs and patients with evolving acute myocardial infarction. J Clin Invest. 1973; 52: 2579-90.

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2. Pollock GD, Bowling N, Tuttle RR, Hayes JS. Effects of Sdobutamine on ischemic myocardium caused by coronary artery narrowing. J Cardiovasc Pharmacol. 1994; 24: 6473. 3. Papadakis EJ, Abel FL. Left ventricular performance in canine endotoxin shock. Circ Shock. 1988; 24: 123-31. 4. Bernardin G, Strosberg AD, Bernard A, Mattei M, Marullo S. Beta-adrenergic receptor-dependent and -independent stimulation of adenylate cyclase is impaired during severe sepsis in humans. Intensive Care Med. 1998; 24: 1315-22. 5. Yoneyama M, Sugiyama A, Satoh Y, Takahara A, Nakamura Y, Hashimoto K. Cardiovascular and adenylate cyclase stimulating effects of colforsin daropate, a watersoluble forskolin derivative, compared with those of isoproterenol, dopamine and dobutamine. Circ J. 2002; 66: 1150-4. 6. Boillot A, Massol J, Maupoil V, Grelier R, Capellier G, Berthelot A, et al. Alterations of myocardial and vascular adrenergic receptor-mediated responses in Escherichia

coli-induced septic shock in the rat. Crit Care Med. 1996; 24: 1373-80. 7. Leone M, Boyadjiev I, Boulos E, Antonini F, Visintini P, Albanèse J, et al. A reappraisal of isoproterenol in goaldirected therapy of septic shock. Shock. 2006; 26: 353-7.

Marc Leone, Claude Martin Service d’Anesthésie et de Réanimation, Hôpital Nord, Assistance Publique Hôpitaux de Marseille, Aix Marseille Université, Marseille, France

Corresponding author: Marc Leone Service d’Anesthésie et de Réanimation, Hôpital Nord, Chemin des Bourrely, 13015 Marseille, France e-mail : [email protected]

Cite this article as: Leone M, Martin C. No coronary artery occlusion in septic shock: Isoproterenol infusion should not be discouraged. Heart, Lung and Vessels. 2015; 7(1): 90. Source of Support: Nil. Conflict of interest: None declared.

Heart, Lung and Vessels. 2015, Vol. 7

No coronary artery occlusion in septic shock: Isoproterenol infusion should not be discouraged.

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