Rosenzweig E B, Starc T J, Chen J M, Cullinane S, Timchak D M, Gersony W M, Landry D W, Galantowicz M E
Columbia University, College of Physicians and Surgeons, Department of Pediatric Cardiology, New York, NY, USA.
Circulation. 1999 Nov 9;100(19 Suppl):II182-6. doi: 10.1161/01.cir.100.suppl_2.ii-182.
Recent investigations at our institution have studied a variety of vasodilatory shock states that are characterized by vasopressin deficiency and pressor hypersensitivity to the exogenous hormone. Our experience in adults prompted the use of arginine-vasopressin (AVP) in a similar group of critically ill children.
This report describes our early experience (from February 1997 through April 1998) in 11 profoundly ill infants and children (5 male, 6 female) ages 3 days to 15 years (median, 35 days) treated with AVP for hypotension after cardiac surgery which was refractory to standard cardiopressors. Although underlying heart disease was present (congenital heart defects in 10 and dilated cardiomyopathy in 1), only 2 patients had severely depressed cardiac function as demonstrated by 2D echocardiogram before administration of AVP. All patients were intubated and receiving multiple catecholamine pressors and inotropes, including dobutamine (n=10), epinephrine (n=8), milrinone (n=7), and dopamine (n=4) before receiving AVP. Five patients received AVP intraoperatively immediately after cardiopulmonary bypass, 5 in the intensive care unit within 12 hours of surgery, and 1 on postoperative day 2 for hypotension associated with sepsis. The dose of AVP was adjusted for patient size and ranged from 0.0003 to 0.002 U. kg(-1). min(-1). During the first hour of treatment with AVP, systolic blood pressure rose from 65+/-14 to 87+/-17 mm Hg (P<0. 0001; n=11), and epinephrine administration was decreased in 5 of 8 patients and increased in 1. Plasma AVP levels before treatment were available in 3 patients and demonstrated AVP depletion (median, 4.4 pg/mL; n=3). All 9 children with vasodilatory shock survived their intensive care unit stay. The 2 patients who received AVP in the setting of poor cardiac function died, despite transient improvement in blood pressure.
Infants and children with low blood pressure and adequate cardiac function after cardiac surgery respond to the pressor action of exogenous AVP. AVP deficiency may contribute to this hypotensive condition.
我们机构最近的研究探讨了多种血管舒张性休克状态，其特征为血管加压素缺乏以及对外源性激素的升压反应过敏。我们在成人患者中的经验促使我们在一组病情严重的儿童中使用精氨酸血管加压素（AVP）。
本报告描述了我们的早期经验（从1997年2月至1998年4月），涉及11名病情严重的婴儿和儿童（5名男性，6名女性），年龄从3天至15岁（中位数为35天），他们在心脏手术后因低血压接受AVP治疗，而这种低血压对标准强心剂治疗无效。尽管存在潜在的心脏病（10例为先天性心脏缺陷，1例为扩张型心肌病），但在给予AVP之前，只有2例患者经二维超声心动图显示心脏功能严重受损。所有患者均已插管，并在接受AVP之前接受多种儿茶酚胺升压药和正性肌力药物治疗，包括多巴酚丁胺（n = 10）、肾上腺素（n = 8）、米力农（n = 7）和多巴胺（n = 4）。5例患者在体外循环后立即在术中接受AVP治疗，5例在术后12小时内在重症监护病房接受治疗，1例在术后第2天因与脓毒症相关的低血压接受治疗。AVP的剂量根据患者体型进行调整，范围为0.0003至0.002 U·kg⁻¹·min⁻¹。在使用AVP治疗的第一小时内，收缩压从65±14 mmHg升至87±17 mmHg（P < 0.0001；n = 11），8例患者中有5例肾上腺素用量减少，1例增加。3例患者在治疗前的血浆AVP水平显示AVP耗竭（中位数为4.4 pg/mL；n = 3）。所有9例血管舒张性休克患儿在重症监护病房住院期间均存活。2例在心脏功能不佳情况下接受AVP治疗的患者死亡，尽管血压有短暂改善。
心脏手术后出现低血压且心脏功能正常的婴儿和儿童对外源性AVP的升压作用有反应。AVP缺乏可能导致这种低血压状态。
