Subramanian Sanjay, Yilmaz Murat, Rehman Ahmer, Hubmayr Rolf D, Afessa Bekele, Gajic Ognjen
Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First Street SW, Rochester 55905, MN, USA.
Intensive Care Med. 2008 Jan;34(1):157-62. doi: 10.1007/s00134-007-0862-1. Epub 2007 Oct 9.
The optimal role of vasopressor therapy in septic shock is not known. We hypothesized that the variability in the use of vasopressors to treat hypotension is associated with subsequent organ failures.
Retrospective observational single-center cohort study.
Tertiary care hospital.
Consecutive patients with septic shock.
Ninety-five patients were enrolled. Serial blood pressure recordings and vasopressor use were collected during the first 12h of septic shock. Median duration of hypotension that was not treated with vasopressors was 1.37h (interquartile range [IQR] 0.62-2.66). Based on the observed variability, we evaluated liberal (duration of untreated hypotension < median) vs. conservative (duration of untreated hypotensionn > median) vasopressor therapy. Compared with patients who received conservative vasopressor therapy, patients treated liberally had similar baseline organ impairment [median Sequential Organ Failure Assessment (SOFA) score 8 vs. 8, p = 0.438] were more likely to be younger (median age 70 vs. 77 years, p = 0.049), to require ventilator support (78 vs. 49%, p < 0.001), and to have progression of organ failures after 24h (59 vs. 37%, p = 0.032). When adjusted for age and mechanical ventilation, early therapy aimed at achieving global tissue perfusion [odds ratio (OR) 0.33, 95% confidence interval (CI) 0.11-0.88), and early adequate antibiotic therapy (OR 0.27, 95% CI 0.09-0.76), but not liberal vasopressor use (OR 2.13, 95% CI 0.80-5.84), prevented progression of organ failures.
In our retrospective study, early adequate antibiotics and achieving adequate global perfusion, but not liberal vasopressor therapy, were associated with improved organ failures after septic shock. Clinical trials which compare conservative vs. liberal vasopressor therapy are warranted.
血管升压药治疗感染性休克的最佳作用尚不清楚。我们推测使用血管升压药治疗低血压的变异性与随后的器官功能衰竭有关。
回顾性观察性单中心队列研究。
三级医疗中心。
连续性感染性休克患者。
纳入95例患者。在感染性休克的最初12小时内收集连续血压记录和血管升压药使用情况。未使用血管升压药治疗的低血压中位持续时间为1.37小时（四分位间距[IQR]0.62-2.66）。基于观察到的变异性，我们评估了宽松（未治疗的低血压持续时间<中位数）与保守（未治疗的低血压持续时间>中位数）血管升压药治疗。与接受保守血管升压药治疗的患者相比，接受宽松治疗的患者基线器官损害相似[序贯器官衰竭评估（SOFA）中位数评分8 vs.8，p = 0.438]，更可能较年轻（中位年龄70 vs.77岁，p = 0.049），需要呼吸机支持（78% vs.49%，p < 0.001），并且在24小时后出现器官功能衰竭进展（59% vs.37%，p = 0.032）。在对年龄和机械通气进行校正后，旨在实现全身组织灌注的早期治疗[比值比（OR）0.33，95%置信区间（CI）0.11-0.88]以及早期充分的抗生素治疗（OR 0.27，95%CI 0.09-0.76），而非宽松使用血管升压药（OR 2.13，95%CI 0.80-5.84），可预防器官功能衰竭进展。
在我们的回顾性研究中，早期充分的抗生素治疗和实现充分的全身灌注，而非宽松的血管升压药治疗，与感染性休克后器官功能衰竭改善相关。有必要开展比较保守与宽松血管升压药治疗的临床试验。
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