title: Sepsis, venous return, and teleology.
abstract: An understanding of heart-circulation interaction is crucial to our ability to guide our patients through an episode of septic shock. Our knowledge has advanced greatly in the last one hundred years. There are, however, certain empirical phenomena that may lead us to question the wisdom of our prevailing treatment algorithm. Three extreme but iatrogenically possible haemodynamic states exist. Firstly, inappropriately low venous return; secondly, overzealous arteriolar constriction; and finally, misguided inotropy and chronotropy. Following an unsuccessful fluid challenge, it would be logical to first set the venous tone, then set the cardiac rate and contractility, and finally set the peripheral vascular resistance. It is hypothesized that a combination of dihydroergotamine, milrinone and esmolol should be superior to a combination of noradrenaline and dobutamine for surviving sepsis.
authors.affiliation: Department of Anaesthesia, Royal Victoria Hospital, 274 Grosvenor Road, Belfast BT12 6BA, UK. Electronic address: rgm310@gmail.com.
authors.forename: R G
authors.initials: RG
authors.lastname: McNeilly
mesh_terms: D000465:Algorithms; D001794:Blood Pressure; D002302:Cardiac Output; D003326:Coronary Circulation / Q000187:drug effects*; D016638:Critical Illness; D004087:Dihydroergotamine / Q000008:administration & dosage; D004280:Dobutamine / Q000008:administration & dosage; D006339:Heart Rate; D006439:Hemodynamics; D006801:Humans; D020105:Milrinone / Q000008:administration & dosage; D008955:Models, Cardiovascular; D009638:Norepinephrine / Q000008:administration & dosage; D011412:Propanolamines / Q000008:administration & dosage; D012772:Shock, Septic / Q000503:physiopathology* / Q000628:therapy*; D018667:Tilt-Table Test; D014655:Vascular Resistance
chemical_list: D011412:Propanolamines; D004280:Dobutamine; D004087:Dihydroergotamine; D020105:Milrinone; C036604:esmolol; D009638:Norepinephrine