(UN)MOTTLING CREW

Iloprost is a powerful vasodilator, but I have never seen it used as an intravenous infusion to improve general microcirculation in septic shock, like in this interesting, albeit very small, case series from Intensive Care Med.

In septic shock, one of big “organs” affected is the microcirculation. In addition to being a vasodilator, iloprost hampers clot formation and induces fibrinolysis, all of which can be beneficial in improving microcirculation in septic shock.

The study
In this proof-of-concept case series of 4 septic shock patients with multiple organ failure and signs of persistent hypoperfusion despite macrohemodynamic optimisation, with the use of fluids and noradrenaline. Patients were aged 72-82 years old, had a mean SAPS2 of 58 and a SOFA score of 11.

Iloprost infusion was given at a max infusion rate of 1-1.5 ng/kg/min. The study did not assess microcirculation directly, but used skin mottling as a surrogate.

Results
All patients improved their mottling appearance within 3 hours of initiation of iloprost infusion. Lactate dropped from 8 to 2, Cardiac Index increased from 2 to 3.2, while MAP remained the same. NA dose was increased slightly from 0.5 to 0.7, and the patients received crystalloids and albumin both before iloprost and during iloprost infusion. 2 of the 4 patients were discharged alive from hospital.

Iloprost improving skin mottling

Discussion
The images from the patients improvement in skin mottling certainly look impressive, although this might be cosmetic without really helping the patient. We also often observe an improving pink look of patients we give inhaled iloprost for reactive pulmonary hypertension, as a small systemic side effect. But in these septic patients, the falling lactate and increasing CI hints that this might also come with a deeper, clinically relevant effect.

Conclusion
It’s a small case series, and mostly just an interesting clinical observation that needs further studying to see if there is real benefit from the very nice looking cosmetic improvement. But the underlying sound theory¬†and the improvements observed might make this something to at least consider in critical septic shock patients with your back against the wall.

Intravenous iloprost to recruit the microcirculation in septic shock patients?, Intensive Care Med, 2017.

This entry was posted in Intensive Care. Bookmark the permalink.

5 Responses to (UN)MOTTLING CREW

  1. Steph rosenberg says:

    Sounds like it would be beneficial in meningococcemia Will It help doc?

    • Thomas D says:

      Well, if it is sepsis with failing microcirculation, it might. But this is not evidence, just a pointer that it could be useful to study this phenomenon more closely.

  2. Steph rosenberg says:

    Dic?

  3. remi nfkb says:

    Hello, thank you for this article.

    Some people also use Isosorbide dinitrate/nitroglycerin in our institution in the same context as in this study.

    french (sorry) thesis : http://pepite-depot.univ-lille2.fr/nuxeo/site/esupversions/6cd41202-2f20-41f6-9a94-d311a3470ba6

    • Thomas D says:

      Interesting! Thanks for the link! Generally, I think we’ve not looked enough into vasodilatory drugs in the setting of sepsis. Vasodilation is also one of the ways dobutamine helps increase cardiac output. We’ll probably see more of these trials in the near future. It will be interesting to see the outcomes!

Leave a Reply

Your email address will not be published. Required fields are marked *