Jellema Wilbert T, Groeneveld A B Johan, Wesseling Karel H, Thijs Lambertus G, Westerhof Nico, van Lieshout Johannes J
Cardiovascular Research Institute Amsterdam, the Department of Internal Medicine, Academic Medical Center, Amsterdam, The Netherlands.
Crit Care Med. 2006 Sep;34(9):2392-8. doi: 10.1097/01.CCM.0000233871.52553.CD.
To establish the heterogeneity of hemodynamic responses to dobutamine in patients with septic shock and to identify the predictive factors of these hemodynamic responses.
Prospective study.
A total of 12 patients with septic shock in a tertiary medical intensive care unit.
A 20-min dobutamine infusion at 5 microg.kg(-1).min(-1) with subsequent increments to 8, 12.6, and 20 microg.kg(-1).min(-1), on two consecutive days. Responses were dichotomized into changes in heart rate (HR) or stroke volume index (SVI) of >10% and < or =10% at the maximal dobutamine infusion.
No differences were found in survival, Acute Physiology and Chronic Health Evaluation II score, maximal dobutamine doses, or pharmacokinetics of dobutamine between HR and SVI groups. In DeltaHR > 10% vs. DeltaHR < or = 10%, baseline HR was lower, and baseline mixed venous oxygen tension and saturation were higher. During dobutamine infusion, mean arterial pressure decreased in DeltaHR > 10%. Cardiac index and the systemic oxygen delivery index increased and the systemic vascular resistance index decreased at unchanged SVI. Pressure work index increased and the ratio of the diastolic to systolic aortic pressure time indices decreased but not to <0.6. In DeltaHR < or = 10%, systemic vascular resistance index and the ratio of the diastolic to systolic aortic pressure time indices decreased (but remained >0.6) without changes in SVI or cardiac index. Baseline hemodynamic and metabolic variables did not differ between SVI groups. In DeltaSVI > 10%, cardiac index increased with dobutamine, but Pao2 and the systemic oxygen delivery index decreased. In DeltaSVI < or = 10%, HR and the systemic oxygen delivery index increased; mean arterial pressure, left ventricular stroke work index, systemic vascular resistance index, and the ratio of the diastolic to systolic aortic pressure time indices decreased.
Patients with a positive chronotropic response to dobutamine had lower baseline HR values, and a chronotropic rather than inotropic response predicted an increase in cardiac index and systemic oxygen delivery index. Incremental dosages of dobutamine did not compromise indirectly measured myocardial oxygen balance.
确定感染性休克患者对多巴酚丁胺血流动力学反应的异质性，并识别这些血流动力学反应的预测因素。
前瞻性研究。
一家三级医疗重症监护病房的12例感染性休克患者。
连续两天以5μg·kg⁻¹·min⁻¹的速度输注多巴酚丁胺20分钟，随后递增至8、12.6和20μg·kg⁻¹·min⁻¹。在最大多巴酚丁胺输注时，将反应分为心率（HR）或每搏量指数（SVI）变化>10%和≤10%。
HR和SVI组在生存率、急性生理与慢性健康状况评估II评分、最大多巴酚丁胺剂量或多巴酚丁胺药代动力学方面未发现差异。在ΔHR>10%与ΔHR≤10%相比时，基线HR较低，基线混合静脉血氧分压和饱和度较高。在多巴酚丁胺输注期间，ΔHR>10%时平均动脉压下降。在SVI不变的情况下，心脏指数和全身氧输送指数增加，全身血管阻力指数下降。压力功指数增加，舒张期与收缩期主动脉压力时间指数的比值下降，但未降至<0.6。在ΔHR≤10%时，全身血管阻力指数和舒张期与收缩期主动脉压力时间指数的比值下降（但仍>0.6），SVI或心脏指数无变化。SVI组之间的基线血流动力学和代谢变量无差异。在ΔSVI>10%时，多巴酚丁胺使心脏指数增加，但动脉血氧分压和全身氧输送指数下降。在ΔSVI≤10%时，HR和全身氧输送指数增加；平均动脉压、左心室每搏功指数、全身血管阻力指数以及舒张期与收缩期主动脉压力时间指数的比值下降。
对多巴酚丁胺有正性变时反应的患者基线HR值较低，变时而非变力反应预示心脏指数和全身氧输送指数增加。多巴酚丁胺递增剂量未损害间接测量的心肌氧平衡。
