Acute and Critical Care

Original Article

Infection
Trajectories of mean arterial pressure/norepinephrine equivalent dose index in patients with septic shock receiving low-dose hydrocortisone: a retrospective cohort study in Thailand: Auttawut Chalermwutanon, Sawangjit Saejaow, Veerapong Vattanavanit; Acute Crit Care. 2026;41(1):107-116. Published online February 9, 2026; DOI: https://doi.org/10.4266/acc.000125

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Background
We aimed to analyze the trajectories of the mean arterial pressure/norepinephrine equivalent dose (MAP/NEQ) index in patients with septic shock treated with low-dose hydrocortisone and to determine the association of these trajectories with mortality. Methods: A retrospective cohort of 203 patients with septic shock receiving low-dose hydrocortisone was examined. MAP and NEQ data were collected from electronic health records, and groupbased trajectory modeling was employed to identify distinct patterns in the MAP/NEQ index over the initial 72 hours of treatment. Univariable and multivariable logistic regression analyses were conducted to assess the associations of MAP/NEQ index trajectories with clinical variables and in-hospital mortality. Results: The overall in-hospital mortality rate was 56.2%. Three MAP/NEQ index trajectory patterns were identified: unchanged (76.8%), gradually increased (14.3%), and rapidly increased (8.9%). The shock reversal rates were 50% for the unchanged group, 89.7% for the gradually increased group, and 100% for the rapidly increased group. Compared with the unchanged group, both gradually and rapidly increased groups were associated with significantly lower mortality, with adjusted odds ratios of 0.15 (95% CI, 0.05–0.40; P<0.001) and 0.29 (95% CI, 0.09–0.92; P=0.035), respectively. Conclusions: In patients with septic shock treated with low-dose hydrocortisone, gradually and rapidly increased MAP/NEQ index trajectories were associated with significantly lower mortality risks and higher rates of shock reversal compared to those with unchanged trajectories. These findings highlight the importance of monitoring the MAP/NEQ index to guide treatment and improve septic shock outcomes.

Citations

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Vascular norepinephrine responsiveness index for early risk stratification in emergency department septic shock: a real-world cohort study from a Latin American sepsis code registry
Miguel Santiago Paiba-Montaña, Juan David Bustos Acosta, Liliana Patricia Acero Galvis, Jonathan Alexander Guezguan Pérez, Yardany Rafael Méndez Fandiño
Frontiers in Medicine.2026;[Epub] CrossRef

Review Article

Neurosurgery
The role of catecholamines in aneurysmal subarachnoid hemorrhage: a narrative review: Samantha Nalliah, Tariq Janjua, Luis Rafael Moscote-Salazar, Md Yunus, Amit Agrawal; Acute Crit Care. 2025;40(4):513-520. Published online November 24, 2025; DOI: https://doi.org/10.4266/acc.001525

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Abstract PDF

The marked release of catecholamines during subarachnoid hemorrhage is an important aspect of the pathobiology following aneurysmal rupture. This narrative review aims to identify how catecholamines influence aneurysmal subarachnoid hemorrhage (aSAH) outcomes. aSAH is a critical neurological condition characterized by hemorrhage into the subarachnoid space, leading to severe neurological deficits and mortality. Catecholamines, including epinephrine, norepinephrine, and dopamine, are the body's stress responses, which can lead to secondary injuries following aSAH. This review was conducted through a targeted literature search of relevant studies examining the relationship between aSAH, catecholamines, and clinical outcomes. Searches were performed in PubMed, Scopus, The Cochrane Library, Medline (Ovid), Embase (Ovid), and CINAHL, including publications up to July 2024. Search terms combined keywords and subject headings related to “subarachnoid hemorrhage” or “aSAH,” “catecholamines,” “epinephrine,” “norepinephrine,” “dopamine,” and outcome-related terms such as “prognosis,” “mortality,” and “neurological outcome.” Articles were selected based on relevance, and key findings were synthesized descriptively to provide a comprehensive overview of current knowledge in this area. Elevated levels of catecholamines are observed following aSAH and are associated with increased sympathetic nervous system activity. This catecholamine surge contributes to pathological processes, including vasospasm, blood-brain barrier disruption, cerebral edema, and neuronal damage. The review highlights the implications of catecholamine levels; where higher concentrations correlate with poorer outcomes and higher mortality rates. Understanding the mechanisms responsible for secondary injury due to catecholamines surge following aSAH shall facilitate the development of therapeutic approaches to prevent secondary brain injury and improve outcomes.

Citations

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Associations Between Serum Liver Enzymes and the Rupture Status of Intracranial Aneurysms
Huan Luo, Lu Yu, Jiayuan Zhang, Qishan Chen, Tian Xu, Chao Yu
Journal of Endovascular Therapy.2026;[Epub] CrossRef
Glymphatic-meningeal lymphatic dysfunction drives remote organ injury after aneurysmal subarachnoid hemorrhage: a unified neuroimmune framework and time-stratified therapeutic roadmap
Ying Dai, Jinshan Tie, Dan Zhu, Zhengchao Lv, Wei Wan, Haolun Chen, Wei Li, Chen Yu
Reviews in the Neurosciences.2026;[Epub] CrossRef
Glucose/Potassium Ratio, a Novel Biomarker for the Prognosis of Patients with Subarachnoid Hemorrhage: A Review
Luis E. Fernández-Garza, Valeria A. Fernández-Garza, Daniela Mares-Custodio, Victor Gutiérrez-Ruano, Alexandro Navarrete-Rodríguez, Juan J. Arias-Alzate
Journal of Vascular Diseases.2025; 4(4): 48. CrossRef

Case Report

Ventricular Fibrillation Soon after Endobronchial Epinephrine Application in a Young Man: A Case Report: Young Min Shin, Jong Hyung Kim, Hyung Wook Kim, Bo Sik Choi, Jin Gyu Jeong, Jung Won Hwang, Kwang Won Seo, Jong Joon Ahn, Seung Won Ra; Korean J Crit Care Med. 2011;26(4):276-280.; DOI: https://doi.org/10.4266/kjccm.2011.26.4.276

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Abstract PDF

Ventricular fibrillation and cardiac arrest rarely occur after local application of epinephrine. Local and superficial application of epinephrine is a common hemostatic method during bronchoscopy, especially after biopsies. Although high plasma levels following endobronchial application of epinephrine have been observed in previous animal studies, there is no report of ventricular fibrillation after a usual dose of endobronchial application of epinephrine during bronchoscopy. We present a case of endobronchial epinephrine-induced ventricular fibrillation and cardiac arrest in a 31-year-old man with no previous history of cardiac disease.

Citations

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Stress Related Cardiomyopathy during Flexible Bronchoscopy
Jung Ar Shin, Ji Yoon Ha, Sang Yong Kim, Byoung Kwon Lee, Hyung Jung Kim, Chul Min Ahn, Yoon Soo Chang
Korean Journal of Critical Care Medicine.2013; 28(2): 127. CrossRef

Original Article

Adequacy of Epinephrine Administration during Advanced Cardiovascular Life Support in terms of Dosing and Intervals between Doses: Seung Joon Lee, Byung Kook Lee, Kyung Woon Jeung, Hyoung Youn Lee, Tag Heo, Yong Il Min, Jong Geun Yun, Jae Hoon Lim; Korean J Crit Care Med. 2011;26(2):69-77.; DOI: https://doi.org/10.4266/kjccm.2011.26.2.69

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Abstract PDF

BACKGROUND
Consensus guidelines clearly define how epinephrine is administered during cardiopulmonary resuscitation (CPR). In South Korea, it is not known whether epinephrine is administered in accordance with the current advanced cardiovascular life support (ACLS) guidelines during actual practice. We sought to investigate adherence to ACLS guidelines during actual CPR in terms of the dose of epinephrine and the interval between doses.
METHODS
A retrospective review of medical records was performed on 394 adult cardiac arrest patients who received CPR at an emergency room. Data including the duration of CPR, the dose of epinephrine, and the interval between doses was collected from CPR records.
RESULTS
Standard-dose epinephrine (1 mg) was used in 166 of 394 patients (42.1%). In 58.8% of patients, the average between-dose interval was within the 3-5 min recommended in the guidelines, whereas it was shorter than 3 min in 31.4% of patients. As a whole, epinephrine was administered in accordance with the current ACLS guidelines in only 96 of 394 patients (24.4%). Logistic regression analysis revealed the duration of CPR to be an independent factor affecting the use of standard-dose epinephrine and the adequate between-dose interval.
CONCLUSIONS
Epinephrine was not administered according to the ACLS guideline in most patients. A national multi-center study is required to determine whether the poor adherence to the ACLS guideline is a widespread problem. In addition, efforts to improve adherence to the ACLS guideline are required.

Citations

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Reply to letter “Improving ROSC with high dose of epinephrine. Are we really?”
Kyung Woon Jeung, Hyun Ho Ryu, Kyung Hwan Song, Byung Kook Lee, Hyoung Youn Lee, Tag Heo, Yong Il Min
Resuscitation.2012; 83(3): e73. CrossRef

Case Report

Topical Epinephrine-soaked Gauze-induced Ventricular Tachycardia during Skin Grafting: A Case Report: Jongyeon Lee, Hyeonjeong Yang, Mingu Kim, Hyunjue Gill, Kuemhee Chung, Sunghee Chung, Jieun Song, Sangwoo Lee; Korean J Crit Care Med. 2009;24(1):42-46.; DOI: https://doi.org/10.4266/kjccm.2009.24.1.42

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Abstract PDF

Topical epinephrine is useful to reduce bleeding during skin grafting. However, even though a clear operative field is obtained, systemic absorption of topical epinephrine can occur and this may cause severe hypertension, arrhythmias, ventricular tachycardia, myocardial ischemia, pulmonary edema, or cardiac arrest. We managed a case of cardiac arrhythmia during general anesthesia, which was induced by gauze soaked in topical epinephrine used for skin grafting of burn wounds. A 26-year-old woman developed premature ventricular complexes and ventricular tachycardia during surgery when epinephrine-soaked gauze was applied to the skin donor and burn wound sites to control oozing. The patient was resuscitated immediately and within 10 minutes the vital signs had normalized. It is recommended that caution is exercised when epinephrine-soaked gauze is applied to a large area of skin.

Citations

Citations to this article as recorded by

Ventricular Fibrillation Soon after Endobronchial Epinephrine Application in a Young Man -A Case Report-
Young Min Shin, Jong Hyung Kim, Hyung Wook Kim, Bo Sik Choi, Jin-Gyu Jeong, Jung Won Hwang, Kwang Won Seo, Jong-Joon Ahn, Seung Won Ra
The Korean Journal of Critical Care Medicine.2011; 26(4): 276. CrossRef

Original Article

The Effect of Low-dose Dopamine on Splanchnic and Renal Blood Flow in Patients with Septic Shock under the Treatment of Norepinephrine: Jong Joon Ahn, Tae Hyung Kim, Ki Man Lee, Tae Sun Shim, Chae Man Lim, Sang Do Lee, Woo Sung Kim, Dong Soon Kim, Won Dong Kim, Younsuck Koh; Korean J Crit Care Med. 2001;16(1):36-41.

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Abstract PDF: BACKGROUND
Norepinephrine, which is frequently administered as a vasopressor to the patients with septic shock, can decrease splanchnic and renal blood flows and aggravate splanchnic and renal ischemia. The low-dose dopamine (LDD) has been frequently combined with norepinephrine to ameliorate renal and splanchnic hypoperfusion in patients with septic shock. However, the effect of the LDD on the splanchnic and renal blood flow has not been fully elucidated. This investigation was carried out to determine the effect of the LDD on the splanchnic and renal blood flow in the patients with septic shock under the treatment of norepinephrine.
METHODS
Eleven patients with septic shock were included in this study. All of them were under the norepinephrine treatment as the mean arterial pressure (MAP) was less than 70 mm Hg in spite of the adequate fluid resuscitation. With stabilization of MAP, the LDD (2 g/kg/min) was administered for two hours in each patients. Hemodynamics, gastric intramucosal pH (pHi), gastric regional PCO2 (rPCO2), rPCO2 - PaCO2, urine volume, urine sodium excretion and creatinine clearance were compared between with and without the LDD infusion. Diuretics was not used during the study period.
RESULTS
Age of patients (n=11) was 64 12 and the APACHE III score was 84 17. The mortality rate of the subjects was 64%. Dosage of norepinephrine was 0.55 0.63 g/kg/min during the study period. There were no significant differences in hemodynamics (central venous pressure, cardiac output, pulmonary artery occlusion pressure, mixed venous gas), pHi, rPCO2, rPCO2 - PaCO2 depending on the concomitant infusion of the LDD. The volume of urine tended to increase (P=0.074) after concomitant LDD, but the changes in urine sodium excretion and creatinine clearance were not significantly different.
CONCLUSIONS
The combined infusion of the LDD with norepinephrine did not improve splanchnic and renal blood flow in the patients with septic shock.

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