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, beta-adrenoreceptors 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.
Footnotes
Source of Support Nil.
Conflict of interest None declared.
Cite 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
References
- Shell W E, Lavelle J F, Covell J W, Sobel B E. Early estimation of myocardial damage in conscious dogs and patients with evolving acute myocardial infarction. J Clin Invest. 1973;52:2579–2590. doi: 10.1172/JCI107450. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Pollock G D, Bowling N, Tuttle R R, Hayes J S. Effects of S-dobutamine on ischemic myocardium caused by coronary artery narrowing. J Cardiovasc Pharmacol. 1994;24:64–73. doi: 10.1097/00005344-199407000-00012. [DOI] [PubMed] [Google Scholar]
- Papadakis E J, Abel F L. Left ventricular performance in canine endotoxin shock. Circ Shock. 1988;24:123–131. [PubMed] [Google Scholar]
- Bernardin G, Strosberg A D, 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;24:1315–1322. doi: 10.1007/s001340050768. [DOI] [PubMed] [Google Scholar]
- Yoneyama M, Sugiyama A, Satoh Y, Takahara A, Nakamura Y, Hashimoto K. Cardiovascular and adenylate cyclase stimulating effects of colforsin daropate, a water-soluble forskolin derivative, compared with those of isoproterenol, dopamine and dobutamine. Circ J. 2002;66:1150–1154. doi: 10.1253/circj.66.1150. [DOI] [PubMed] [Google Scholar]
- 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;24:1373–1380. doi: 10.1097/00003246-199608000-00017. [DOI] [PubMed] [Google Scholar]
- Leone M, Boyadjiev I, Boulos E, Antonini F, Visintini P, Albanèse J. et al. A reappraisal of isoproterenol in goal-directed therapy of septic shock. Shock. 2006;26:353–357. doi: 10.1097/01.shk.0000226345.55657.66. [DOI] [PubMed] [Google Scholar]