Benchekroune Samir, Karpati Peter C J, Berton Christine, Nathan Cédric, Mateo Joaquim, Chaara Mansour, Riché Florence, Laisné Marie-Josèphe, Payen Didier, Mebazaa Alexandre
Department of Anesthesiology and Intensive Care, Lariboisière University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.
J Trauma. 2008 May;64(5):1188-95. doi: 10.1097/TA.0b013e31811f3a45.
Emphasis in therapy of human septic shock is shifting towards reliable end points and predictors of survival. Rationale is to study whether the evolution of cardiovascular reactivity in view of the administered doses of norepinephrine is an early predictor of in-hospital survival and to determine the optimal threshold of norepinephrine therapy and its consequences on renal function.
Observational study of a prospective cohort of patients in septic shock, hospitalized in intensive care unit at least 24 hours before requiring norepinephrine. Excluded were patients requiring <72 hours of continuous norepinephrine (16 patients) or who received corticosteroids. Hemodynamic parameters (heart rate, blood pressure, urinary output, and temperature) were continuously monitored.
Of 68 patients, 45 survived [intensive care unit stay of 24 (12-36) days, hospital stay of 36 (27-66) days], and 23 died 5 (3-10) days after septic shock onset and norepinephrine treatment. Multivariate analysis revealed four independent positive predictive factors of short-term (10 days) outcome: Simplified Acute Physiology Score (SAPS) II <50 [odds ratio (OR) 6.4, 95% confidence interval (95% CI) 1.3-30.7, p < 0.011], and on day 3 Logistic Organ Dysfunction System (LODS) score <6 (OR 29.1, 95% CI 2.7-314.3, p = 0.0056), norepinephrine concentration <0.5 mug/kg/min (OR 17.6, 95% CI 2.2-142.0, p < 0.0007), diastolic arterial pressure >50 mm Hg (OR 24.8, 95% CI 2.9-215.9, p < 0.004), but not systolic arterial pressure.
Septic shock survival increases when dose of 0.5 mug/kg/min of norepinephrine continuously improves vascular tone within the first 48 hours, or when diastolic arterial pressure (>50 mm Hg) is restored. Norepinephrine has beneficial effects on renal function. Predictive value of LODS score on day 3 is demonstrated, while SAPS II is confirmed as the only reliable predictive factor in first 24 hours.
人类感染性休克治疗的重点正转向可靠的终点指标和生存预测因素。目的是研究根据去甲肾上腺素给药剂量观察到的心血管反应性变化是否是住院生存的早期预测指标，并确定去甲肾上腺素治疗的最佳阈值及其对肾功能的影响。
对一组感染性休克患者进行前瞻性队列观察研究，这些患者在需要去甲肾上腺素治疗前至少在重症监护病房住院24小时。排除那些需要连续使用去甲肾上腺素少于72小时的患者（16例）或接受过皮质类固醇治疗的患者。连续监测血流动力学参数（心率、血压、尿量和体温）。
68例患者中，45例存活[重症监护病房住院时间为24（12 - 36）天，住院时间为36（27 - 66）天]，23例在感染性休克发作和去甲肾上腺素治疗后5（3 - 10）天死亡。多因素分析显示了短期（10天）预后的四个独立阳性预测因素：简化急性生理学评分（SAPS）II<50[比值比（OR）6.4，95%置信区间（95%CI）1.3 - 30.7，p<0.011]，以及在第3天逻辑器官功能障碍系统（LODS）评分<6（OR 29.1，95%CI 2.7 - 314.3，p = 0.0056），去甲肾上腺素浓度<0.5μg/kg/min（OR 17.6，95%CI 2.2 - 142.0，p<0.0007），舒张压>50mmHg（OR 24.8，95%CI 2.9 - 215.9，p<0.004），但收缩压不是。
当去甲肾上腺素剂量为0.5μg/kg/min在最初48小时内持续改善血管张力，或舒张压恢复（>50mmHg）时，感染性休克患者的生存率会提高。去甲肾上腺素对肾功能有有益影响。证实了第3天LODS评分的预测价值，而SAPS II被确认为最初24小时内唯一可靠的预测因素。
