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3/9 ⚠️ Even if hypotension were the cause of adverse events, there’s no proof that preventing it reduces them. 💔 Interventions aimed at lowering hypotensive episodes haven’t successfully decreased adverse outcomes. ncbi.nlm.nih.gov/pmc/articles/P…

4/9 Not all hypotensions are the same. Blood pressure doesn’t equal end-organ flow. 🚫 Flow= arterial pressure - venous pressure/resistance. MAP= CO x R + CVP. Increasing resistance raises MAP but reduces flow. ⬆️🔄⬇️ pubs.asahq.org/anesthesiology… ncbi.nlm.nih.gov/pmc/articles/p…

5/9 ..and the same holds true for central venous pressure. ⚖️ ncbi.nlm.nih.gov/pmc/articles/p…

6/9 The interventions we use to increase blood pressure come with costs that may counterbalance: •Arrhythmia⚡ •Increased backpressure on vascular beds🔄 •Elevated metabolism 🔥 •Hyperglycemia 🍬 •Hypoperfusion ❄️ •Skin necrosis 🩹 •Increased LV afterload 💔

7/9 One size fits all? Not quite. Some people comfortably tolerate MAP levels below 65mmHg. 🌙 Consider this: a third of patients monitored the night before surgery spontaneously dropped below 65mmHg. pubs.asahq.org/anesthesiology…

8/9 And the lower limit of organ autoregulation is subjective: 🧬 Influenced by medications, existing conditions, and likely lower than what's identified in animal studies. kidney-international.org/article/S0085-…

9/9 🌟 For all these reasons, whether individually or collectively, we can assert that protective hemodynamics is the future of managing both critical and perioperative patients. We must consider flow and harms of our interventions in an advanced vision of hemodynamic management

Read the letter to our meta-analysis and our response in the latest issue of Critical Care Medicine. Critical Care Medicine Giovanni Landoni, MD Alessandro Pruna, MD Zbigniew Putowski journals.lww.com/ccmjournal/cit…

#Angiotensin II for the management of distributive shock: expert consensus statement A group of Italian ICU specialists including Andrea Cortegiani Prof. ELENA GIOVANNA BIGNAMI Katia Donadello fabio guarracino Gianluca Paternoster Girardis Massimo published today open access Journal of Anesthesia, Analgesia and Critical Care link.springer.com/article/10.118…

Steven Mathern Giovanni Landoni, MD Michael Mazzeffi Filippo D'Amico Alessandro Pruna, MD Todd C. Lee I doubt there will ever be a clear threshold. MAP is kind of like CVP - the same value can mean completely two different flow-resistance situations. This meta analysis suggests that doing ‚more’ by uniform MAP uptitration is overall worse than doing less. No clear value though

Zbigniew Putowski Steven Mathern Giovanni Landoni, MD Michael Mazzeffi Filippo D'Amico Alessandro Pruna, MD I still see people on pressors with map 70+ because enough attention isn't paid to the top end. Others map 60 on pressors and eating a sandwich and being on pressors where the map doesn't match the patient. I think this paper suggests we need to have some pressor stewardship

Zbigniew Putowski Steven Mathern Giovanni Landoni, MD Michael Mazzeffi Filippo D'Amico Alessandro Pruna, MD Here's an interesting exercise. The next time you're in your ICU count the number of patients with maps above 70 who are receiving norepinephrine.

The use of angiotensin II for the management of distributive shock: expert consensus statements Giovanni Landoni, MD CCR Journal Watch criticalcarereviews.com/latest-evidenc… Get the latest critical care literature every weekend via the CCR Newsletter - subscribe at criticalcarereviews.com/newsletters/su…

Fluids are good but not in pts with advanced chronic kidney disease! a subgroup analysis of #CLOVERtrial suggests mortality increase survival benefit in restrictive versus liberal fuid management for sepsis-induced hypotension in pts with advanced CKD pubmed.ncbi.nlm.nih.gov/38992663/

Our #PROTECTIONtrial, which demonstrated that amino acids infusion reduces the occurrence of AKI in adults undergoing cardiac surgery, has been published in today’s issue of NEJM. Article: nej.md/45zYDyF Editorial: nej.md/3WKT3Fi Video: nejm.org/do/10.1056/NEJ…

Minimal intraoperative blood pressure threshold and postoperative outcomes. New correspondence by D'Amico et al #bloodpressure #hypotension #anaesthesia bjanaesthesia.org/article/S0007-…

Randomized studies consistently show that intraoperative hypotension is not the cause of adverse events. Continuing RASIs increases episodes and duration of hypotension but has no impact on mortality or adverse events (1.02 [0.87-1.19]) Giovanni Landoni, MD Ashish K. Khanna, MD,MS,FCCP,FCCM,FASA

Filippo D'Amico Giovanni Landoni, MD Ashish K. Khanna, MD,MS,FCCP,FCCM,FASA Finally a negative study that I have been waiting for

Hindex 100 (Scholar) from this week! I'm available and willing to be involved in European / International ICU grant applications. please DM I always find it difficult to identify the correct call I'm tagging below top physician with recent publications in the ICU field

#PREHABILITATION is THE hot topic in perioperative medicine In #Florence there is an ongoing fantastic program and many patients are screened and prehabilitated Prof Gabriele Baldini and Stefano Romagnoli are leading the project and will present us their impressive activity tomorrow