多巴胺、去甲肾上腺素和肾上腺素对脓毒性休克内脏循环的影响：哪种最佳？

Effects of dopamine, norepinephrine, and epinephrine on the splanchnic circulation in septic shock: which is best?

作者信息

De Backer Daniel, Creteur Jacques, Silva Eliézer, Vincent Jean-Louis

机构信息

Department of Intensive Care, Erasme University Hospital, Free University of Brussels, Route de Lennik 808, B-1070 Brussels, Belgium.

出版信息

Crit Care Med. 2003 Jun;31(6):1659-67. doi: 10.1097/01.CCM.0000063045.77339.B6.

DOI:10.1097/01.CCM.0000063045.77339.B6

PMID:12794401

Abstract

OBJECTIVE

To assess the effects of different doses of dopamine, norepinephrine, and epinephrine on the splanchnic circulation in patients with septic shock.

DESIGN

Prospective, randomized, open-label study.

SETTING

A 31-bed, medicosurgical intensive care unit of a university hospital.

PATIENTS

Convenience sample of 20 patients with septic shock, separated into two groups according to whether (moderate shock group, n = 10) or not (severe shock, n = 10) dopamine alone was able maintain mean arterial pressure >65 mm Hg.

INTERVENTIONS

Dopamine was progressively withdrawn and replaced successively by norepinephrine and then epinephrine (the order of the two agents was randomly determined) to maintain mean arterial pressure constant (moderate shock) or to increase mean arterial pressure above 65 mm Hg (severe shock).

MEASUREMENTS AND MAIN RESULTS

Systemic circulation (pulmonary artery catheter) and splanchnic circulation (indocyanine green dilution and hepatic vein catheter) and gastric mucosal Pco(2) (gas tonometry) were measured during dopamine (moderate shock only), norepinephrine, and epinephrine administration (both groups). Data were analyzed with nonparametric tests and are presented as median [percentiles 25-75]. In moderate shock, cardiac index was similar to dopamine and norepinephrine (3.1 [2.7-3.8] vs. 2.9 [2.7-4.1] L/min.m2, p = nonsignificant) but greater with epinephrine (4.1 [3.5-4.4] p <.01 vs. dopamine and norepinephrine). Splanchnic blood flow was similar with the three agents (732 [413-1483] vs. 746 [470-1401] vs. 653 [476-1832] mL/min.m, p = nonsignificant). The gradient between mixed-venous and hepatic venous oxygen saturations was lower with dopamine than with norepinephrine and epinephrine, but the Pco(2) gap was similar with the three agents. In severe shock, cardiac index was higher, but splanchnic blood flow was lower, with epinephrine than with norepinephrine (4.6 [3.7-5.3] vs. 3.4 [3.0-4.1] L/min.m2, p <.01 and 860 [684-1334] vs. 977 [806-1802] mL/min.m2, p <.05, respectively). Epinephrine increased the mixed-venous and hepatic venous oxygen saturation gradient but did not alter Pco(2) gap.

CONCLUSIONS

Dopamine and norepinephrine have similar hemodynamic effects, but epinephrine can impair splanchnic circulation in severe septic shock.

摘要

目的

评估不同剂量的多巴胺、去甲肾上腺素和肾上腺素对感染性休克患者内脏循环的影响。

设计

前瞻性、随机、开放标签研究。

地点

一所大学医院的拥有31张床位的内科外科重症监护病房。

患者

20例感染性休克患者的便利样本，根据单独使用多巴胺能否维持平均动脉压>65 mmHg分为两组（中度休克组，n = 10）或不能维持（重度休克组，n = 10）。

干预措施

逐渐停用多巴胺，依次用去甲肾上腺素和肾上腺素替代（两种药物的顺序随机确定），以维持平均动脉压恒定（中度休克）或使平均动脉压升高至65 mmHg以上（重度休克）。

测量指标及主要结果

在使用多巴胺（仅中度休克）、去甲肾上腺素和肾上腺素期间（两组均进行），测量体循环（肺动脉导管）、内脏循环（吲哚菁绿稀释法和肝静脉导管）以及胃黏膜Pco₂（气体张力测定法）。数据采用非参数检验进行分析，并以中位数[第25 - 75百分位数]表示。在中度休克中，心脏指数在多巴胺和去甲肾上腺素时相似（3.1 [2.7 - 3.8] 对 2.9 [2.7 - 4.1] L/min·m²，p = 无显著差异），但在肾上腺素时更高（4.1 [3.5 - 4.4]，与多巴胺和去甲肾上腺素相比，p <.01）。三种药物的内脏血流量相似（732 [413 - 1483] 对 746 [470 - 1401] 对 653 [476 - 1832] mL/min·m，p = 无显著差异）。多巴胺时混合静脉血与肝静脉血氧饱和度之间的梯度低于去甲肾上腺素和肾上腺素，但三种药物的Pco₂差值相似。在重度休克中，肾上腺素时心脏指数较高，但内脏血流量低于去甲肾上腺素（4.6 [3.7 - 5.3] 对 3.4 [3.0 - 4.1] L/min·m²，p <.01；860 [684 - 1334] 对 977 [806 - 1802] mL/min·m²，p <.05）。肾上腺素增加了混合静脉血与肝静脉血氧饱和度梯度，但未改变Pco₂差值。