The Management of Septic Shock - Literature review Example

LITERATURE REVIEW By Location Search Strategy The Google scholar was used in the identification of the article to be reviewed in this assignment. In addition, a rigorous search from the university library and the PubMed database also produced numerous articles. However, there was a salient need to customize the advanced search settings in a bid to gain access to the most relevant and recent range of articles. Therefore, limits defined for results included full text research articles, peer reviewed and from journals. Moreover, limiting the search to articles dated 2007 to 2012 was a necessary customization. The search words ‘use of dopamine and norepinephrine in the management of septic shock’ served as the determinant for the desired article. As expected, numerous articles addressing this issue appeared and an analysis of the abstracts done to determine relevance (Aveyard 2010, p. 87). Among these articles, one of the most recent and relevant was chosen for a rigorous critique. However, the related articles were of invaluable use in the critical analysis of the findings (Parahoo 2006, p. 54). The article under review in this paper is Patel, GP, et al 2010, Efficacy, and safety of dopamine versus norepinephrine in the management of septic shock, SHOCK, 33 (4): 375- 380. Rationale and Justification As an anaesthesia technician assigned responsibilities in the intensive care unit, it is critical to have an advanced understanding of the management of the septic shock (Cottrell 2011, p. 91). Although medical practitioners in the management of septic shock have applied various intervention strategies, it remains evident that septic shock is a proven cause of death (Cottrell 2011, p. 91). Despite the use of antibiotics, vasopressors, and exerting control on the source of the sepsis, mortality is high. This places emphasis on the need for evidence-based practice when administering vasopressors to septic shock patients (Patel et al 2010, p. 375). Since 2004, primary research findings have suggested the use of norepinephrine and dopamine as potential vasopressors in the management of blood pressure in septic shock patients. Evidently, research has suggested that dopamine presents certain undesirable effects in patients. In a bid to understand the differences between the efficacies of the two drugs, a rigorous critique of the article published by Patel and his colleagues will follow. Critique of Research Rigour Sampling Strategy The researchers identified the Rush university medical centre patients as the target group. Only patients aged above 18 and those placed in the intensive care unit, presenting a positive diagnosis of septic shock after a resuscitation process were eligible (Patel et al 2010, p. 376). A randomized process of the administration of the two drugs followed, with 50 % of the patients receiving dopamine while the rest received epinephrine as the administered vasopressor (Bowling 2009, p. 67). The authors considered 252 patients during the five years research (Patel et al 2010, p. 376). The sampling strategy is of critical consideration in any research because the sample size determines the validity of the results (Cottrell 2011, p. 91). In this research, the researchers relied on a power analysis, expecting the intervention of administering either dopamine or epinephrine to register a 20 % reduced mortality from the expected 40-60 % mortality rate of septic shock (Patel et al 2010, p. 377). Therefore, the sample size needed to be 240, as a minimal figure would not yield the expected 80% power (Patel et al 2010, p. 378). It is remarkable that the authors settled for a single centre, as this made data collection manageable (Bowling 2009, p. 77). Research Methods Evidently, research methods are of salient significance in any research. As many experts have described, researchers should define the most relevant research methods depending on the research problem (Bowling 2009, p. 67). A prospective and protocol-controlled study of the efficacy of the administered dopamine and epinephrine in the enrolled patients was the adopted research method (Patel et al 2010, p. 375). The researchers had defined both primary and secondary endpoints that served as a criterion of comparison of the efficacy of the two drugs (Patel et al 2010, p. 376). A 28-day mortality period was defined as the primary endpoint, while secondary endpoints sought to determine the physiologic effects associated with the administration of both drugs (Vasu et al 2012, P. 172). Some of the secondary end points considered were organ dysfunction, period of stay in the intensive care unit and the and in the medical centre, and prevalence of cardiac arrhythmia (Patel et al 2010, p. 378). In a bid to monitor the occurrence of arrhythmia, patients were placed on a monitoring electrocardiogram (Patel et al 2010, p. 377). Data Collection and Processing In any research, researchers endeavour to rely on efficient data collection strategies. Evidently, Patel and his colleagues embarked on an extensive data collection period spanning from 2003 to 2008 (Patel et al 2010, p. 378). During this period, the enrolled patients were under a consistent monitoring after the administration of either dopamine or epinephrine (Patel et al 2010, p. 377). Clearly, the assumption of the researchers was that the research would conform to the definitions of a power analysis that would exhibit a mortality rate of between 40-60 percent in the 28-day period (Patel et al 2010, p. 378). However, with the intervention of administering either dopamine or epinephrine, the researchers expected an evident reduction in mortality of about 20% (Patel et al 2010, p. 378). The researchers were keen to record specific data of each patient such as age, sex, cause of illness, history of cardiac problems, diagnosed laboratory parameters, and the observational results of both the primary and secondary endpoints (Patel et al 2010, p. 378). After data collection, SPSS was used for analysis, with researchers relying on chi-square and t-tests in the comparison of the two groups (Vasu et al 2012, P. 172). Steps taken to Minimize Bias Without doubt, the researchers endeavour to minimize any form of bias by ensuring that all patients registered a positive diagnosis of septic shock after resuscitation, and a similar administration protocol utilized for both groups (Bowling 2009, p. 64). The researchers ensured that all the patients were under analgesia, sedation, respiratory support, and a weaning protocol observed. Prior to enrolment, patients had to demonstrate balanced characteristics (Vasu et al 2012, P. 173). Conclusions Justified by Research Findings As expected, the conclusions drawn conform to the research findings, as there is a lack of evidence to prove that either one of the drugs exhibited a higher efficacy (Bowling 2009, p. 69). However, the concern lies with the observed cardiac arrhythmia observed after dopamine administration. Clarity of Discussion and Presentation The authors embarked on an extensive discussion explaining the findings, and interpreting data (Patel et al 2010, p. 378). The use of tables and charts enhances the ease of reading. Notably, the work is well-presented with relevant subheadings, and a relevant abstract (Patel et al 2010, p. 375). The main study findings and implications for practice From the consideration of the primary end point, it became evident that the overall mortality rate in the 28-day period was 47%. However, mortality rate after dopamine administration was 50%, while the rate after epinephrine administration was 43% (Patel et al 2010, p. 378). In practice, both drugs exhibit the same level of efficacy. There was no significant difference in the secondary endpoints for between the two groups, except for the increased arrhythmia after the administration of dopamine (Gordon et al 2013, p. 594). The dopamine group exhibited a 38% occurrence of arrhythmia, compared to 11 percent in the epinephrine group (Gordon et al 2013, p. 594). Therefore, administration of epinephrine is a better choice in practice. Physiological Implications The administration of drugs presents varying physiological implications depending on its mechanism of functioning (Gordon et al 2013, p. 594). Although both dopamine and epinephrine are vasopressors with a definite potential to exert control on blood pressure, they exhibit different mechanisms (Gordon et al 2013, p. 594). The fact that the results indicated an increased rate of arrhythmia after the administration of dopamine serves as a justification for the analysis of the physiological implications of the drug (Gordon et al 2013, p. 594). Although patients suffering septic shock register a high vulnerability to cardiac arrhythmia, the findings from the research exhibit an increased level of occurrence of such arrhythmia. Other researches indicate that the rate of cardiac arrhythmia exhibited in the epinephrine group conforms to the expected rate in critical septic shock (Patel et al 2010, p. 378). This serves to highlight that epinephrine does not present undesired physiological implications (Gordon et al 2013, p. 594). However, the dopamine case presents data that would prompt further research. Previous research has attributed the increased cardiac arrhythmia to its mechanism that surrounds the β1 receptor of the myocardium (Patel et al 2010, p. 377). The interaction of dopamine with this receptor presents, explains why the group of dopamine exhibited a higher prevalence of cardiac arrhythmia (Gordon et al 2013, p. 594). Such interactions also place emphasis on the need to understand other effects exerted on the hormonal system that present additional physiological implications (Gordon et al 2013, p. 594). Management and introduction to change of practice After a critical analysis of the findings in the prospective study carried out by Patel et al (2010), it becomes evident that it offers invaluable strategies for improving practice (Hollenberg 2007, p. 1688). Many times clinicians face the compulsion of making the best choice of vasopressors, especially with the increasing number of available drugs (Hollenberg 2007, p. 1688). The research offers a critical comparison of dopamine and epinephrine, two of the vasopressors recommended by the Society of Critical Care Medicine in 2008 after the emergence of increased research highlighting their efficacy (Patel et al 2010, p. 378). Critical care medicine is one of the units that place a salient compulsion for practitioners to make the right decisions, in a bid to promote survival (Nguyen et al 2007, p. 1110). Such urgency and compulsion places emphasis on the need for evidence-based research that practitioners can rely on (Wheeler 2007, p. 1970). The work of Patel et al (2010) offers such evidence-based research that can serve as a guideline in the choice of an effective vasopressor (Greenhalgh 2010, p. 98). Evidently, administration of epinephrine presents a remarkable level of efficacy, and reduces the occurrence of cardiac arrhythmia (Yentis et al 2009, p. 90). Notably, cardiac arrhythmia is a life-threatening condition, and may present fatalities (Russell et al 2008, p. 880). With such critical revelations, the work of Patel et al (2010) has the potential of influencing practice positively (Greenhalgh 2010, p. 98). Legal and ethical issues Critical care medicine requires the observance of certain legal and ethical principles (McLean and Mason 2009, p. 65). Notably, patients in the Intensive Care unit require advanced care because of the high mortality rate (McLean and Mason 2009, p. 85). In the case of septic shock, the mortality rate is rated between 40-60 percent (Patel et al 2010, p. 378). Legally, it is the duty of practitioners to save lives, by offering the required medical attention (Daley et al 2013, p. 304). Moreover, ethical principles assert that the decisions made by medical practitioners should present maximum benefits to the patient. According to the modern understanding of utilitarianism, medical practice depends on the potential benefits of each policy (Fleisher 2009, p. 87). In this case, the administration of both dopamine and epinephrine are interventions adopted with the goal of promoting survival in septic shock patients (Patel et al 2010, p. 378). In a bid to justify the trial carried out by Patel et al (2010) sought legal permission (McLean and Mason 2009, p. 65). The application of the findings in critical medical care requires ethical consideration (Daley et al 2013, p. 304). Although both drugs register efficacy, administering epinephrine presents more benefits (Overrgaard and Dzavik 2008, p. 1050). With this revelation, it would be unethical to administer dopamine in certain situations because of its potential to increase cardiac arrhythmia (Gwinnutt 2008, p. 76). Conclusion Evidently, Patel et al (2010) endeavoured to compare the efficacy of dopamine and epinephrine, two of the vasopressors administered to septic shock patients. The researchers adopted a prospective research method, with a sample size of 252 patients from a single medical centre. The sample accounted for the expected 80% power, conforming to the target of mortality by 20%. According to the findings from this research, it becomes evident that the mortality rate difference exhibited by the drugs was insignificant. However, dopamine caused a remarkably high rate of cardiac arrhythmia, a factor resulting from its mechanism. Bibliography Aveyard, H 2010, Doing a literature review in health and social care: a practical guide, Maidenhead, McGraw-Hill/Open University Press. Bowling, A 2009, Research methods in health: investigating health and health services, Maidenhead, Berkshire, England, McGraw Hill/Open University Press. CottrelL, S 2011, Critical thinking skills: developing effective analysis and argument, Basingstoke, Palgrave Macmillan. Daley et al 2013, A Comparison of Initial Monotherapy with Norepinephrine Versus Vasopressin for Resuscitation in Septic Shock, The Annals of Pharmacotherapy, 47: 301-310. Fleisher, LA 2009, Evidence-based practice of anaesthesiology: Expert consultant 2nd ed, Philadelphia, Saunders. Gordon, A et al , 2013, The Cardiopulmonary Effects of Vasopressin Compared With Norepinephrine in Septic Shock, CHEST 142(3):593–60. Greenhalgh, T 2010, How to read a paper the basics of evidence-based medicine, Chichester, West Sussex, UK, Wiley-Blackwell. Gwinnutt, CL 2008, Lecture Notes on Clinical Anaesthesia 3rd Edition, Oxford: Blackwell Publishing. Hollenberg, SM 2007, Vasopressor support in septic shock. CHEST 132:1678-1687. McLean, S. and Mason, JK 2009, Legal and ethical aspects of healthcare, Cambridge, Cambridge University Press. Nguyen HB, et al 2007, Implementation of a bundle of quality indicators for the early management of sepsis and septic shock is associated with decreased mortality, Crit Care Med 35:1105-1112. Overrgaard CB, and Dzavik, V 2008, Inotropes and vasopressors: review of physiology and clinical use in cardiovascular disease. Circulation, 118:1047- 1056. Parahoo, K 2006, Nursing research: principles, process and issues, London, Palgrave Macmillan. Patel, GP et al 2010, Efficacy, and safety of dopamine versus norepinephrine in the management of septic shock, SHOCK, 33 (4): 375- 380. Russell JA, et al 2008, VASST Investigators: Vasopressin versus norepinephrine infusion in patients with septic shock. N Engl J Med 358:877-887. Vasu, T et al 2012, Norepinephrine or Dopamine for Septic Shock: Systematic Review of Randomized Clinical Trials, Journal of Intensive Care Medicine, 27 (3) 172. Wheeler, AP 2007, Recent developments in the diagnosis and management of severe sepsis, CHEST 132:1967-1976. Yentis, SM et al 2009, Anaesthesia and Intensive Care A to Z: an encyclopaedia of principles and practice 4th ed, New York, Elsevier. Read More