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recognition of cardiac ryhtm disturbance

associated with da used did not result in an increased in mortality


this observation raises concern over the continued use of this agent when there
are alternative vassopressor that do not seem to pose the same risk

Current society of critical care medicine guidelines do not recommend one


catecholamine over another , but the consensus is that there are physiologic
advantages of both medications in the setting of septic shock

consensus

Mechanism by which DA is thought to precipitate more arrythmias has been


linked to its properties and action on the myocardium
concern for the effec

In addition to increased heart rate, there is also concern for the effect on the
hormones controlled by the anterior pituitary and adverse effect from low dose
DA

emphasize
there have been few prospective, randomized, protocol control trial of NE versus
DA IN patients with septic shoc
ber
previous trials included small number of patients and or were obsevational
studies that limit their clinical utility

prospectively evaluated DA
the study was performed in a single MICU that allowed for a more uniform
approach to patient management and one that used a spesific vassopressor
dosing and titration ptotocol to minimize variation of management

in addition to the protocol to guide vasopressor management, this study


incorporated protocols and bundles of care to guide sepsis management,
ventilator management, sedation, and glucose control

assessment of adequacy
assessment of adequacy of source control
adrenal
replacement therapy when indicated
assessment for use activated protein C therapy in addition to the goal directed
safety analysis along with the efficacy evaluation
untoward event
for the occurance
might lead to a change in therapy or an adverse outcome
it was thought to be necessary for the succesful conduct of this study
early administration of the necessary vasopressor support
a more complex randomization procedure may have produced a delay in the
start of necessary vasopressor support and would have made it difficult to begin
correct vasopressor support in the emergency room or hospital ward before the
patient arived in the micu
Despite our use of the even/odd enrollment procedure, it was seem that the
randomization
was the use of single center
however we would suggest that the external validity
compromised by this approach
is representative of the typical university or tertiary care MICU
was critically ill
this high level of acuity is higher than typical multicenter trials investigating
iinovative therapeutic strategies in patients with severe sepsis and septic shock
because we only enrolled
and did not exclude
had preexisting malignancy

immunocompromised state
compromise
therefore, it may be argued
more reflective of a true micu septic shock population as opposed to the patients
enrolled in most multicenter pharmaceutical trials

in addition, the use of MAP of greater than 60 mmhg


both represent accepted guideline goals for resucitated