Dudkiewicz Michael, Proctor Kenneth G
Dewitt-Daughtry Family Department of Surgery, Division of Trauma, University of Miami Miller School of Medicine, Miami, FL, USA.
Crit Care Med. 2008 Sep;36(9):2641-50. doi: 10.1097/CCM.0b013e3181847af3.
Phenylephrine is often used for management of cerebral perfusion pressure after traumatic brain injury, but can have undesirable actions. Few studies have evaluated alternatives. The hypothesis was that arginine vasopressin was as effective as phenylephrine for maintaining tissue oxygenation during cerebral perfusion pressure management.
Prospective randomized, blinded animal study.
University laboratory.
Thirty-five anesthetized swine (46 +/- 1 kg).
Blunt trauma to the head and bilateral chests (estimated injury severity score was 25-32) was followed by hypoventilation. Resuscitation was divided into phases to simulate treatment in a typical prehospital, emergency room, and intensive care unit. For 30-45 mins postinjury, 1 L of normal saline was administered. For 45-120 mins, normal saline maintained systolic blood pressure >100 mm Hg plus mannitol for intracranial hypertension. After 120 mins, phenylephrine or arginine vasopressin was titrated to cerebral perfusion pressure >70 mm Hg (randomized and blinded) plus normal saline to maintain filling pressure >12 mm Hg plus glucose to maintain normoglycemia.
Mortality rate was 37% (13 of 35) within 2 hrs. Before resuscitation, mean arterial pressure was 61 +/- 5 mm Hg, heart rate was 110 +/- 6 beats/min, PaO2 was 46 +/- 2 mm Hg, and lactate was 5.0 +/- 0.4 mM. Intracranial pressure increased from 8 +/- 1 mm Hg to 20 +/- 1 mm Hg and brain tissue PO2 decreased from 19 +/- 1 mm Hg to 8 +/- 1 mm Hg. Resuscitation corrected most variables, as well as mixed venous, renal, portal, and muscle oxygen saturations, but 90% (20 of 22) required pressor support. After 6 hrs with either pressor, hemodynamics were stable. However, with phenylephrine vs. arginine vasopressin, intracranial pressure averaged >10 mm Hg higher and brain tissue PO2 was 6 mm Hg lower, whereas tissue oxygen saturations were >10% higher in the shoulder and hindlimb muscles (all p < 0.05).
Arginine vasopressin was as effective as phenylephrine for maintaining cerebral perfusion pressure, but intracranial pressure and brain tissue oxygenation were improved at the expense of the periphery.
去氧肾上腺素常用于创伤性脑损伤后脑灌注压的管理，但可能会产生不良作用。很少有研究评估其替代药物。研究假设为，在脑灌注压管理期间，精氨酸加压素在维持组织氧合方面与去氧肾上腺素效果相当。
前瞻性随机、盲法动物研究。
大学实验室。
35头麻醉猪（体重46±1千克）。
头部和双侧胸部钝性创伤（估计损伤严重程度评分为25 - 32）后进行通气不足处理。复苏分为几个阶段，以模拟典型的院前、急诊室和重症监护病房的治疗。伤后30 - 45分钟，给予1升生理盐水。45 - 120分钟，用生理盐水维持收缩压>100毫米汞柱，并用甘露醇治疗颅内高压。120分钟后，将去氧肾上腺素或精氨酸加压素滴定至脑灌注压>70毫米汞柱（随机且盲法），并用生理盐水维持充盈压>12毫米汞柱，用葡萄糖维持血糖正常。
2小时内死亡率为37%（35头中的13头）。复苏前，平均动脉压为61±5毫米汞柱，心率为110±6次/分钟，动脉血氧分压为46±2毫米汞柱，乳酸为5.0±0.4毫摩尔/升。颅内压从8±1毫米汞柱升至20±1毫米汞柱，脑组织氧分压从19±1毫米汞柱降至8±1毫米汞柱。复苏纠正了大多数变量，以及混合静脉、肾、门静脉和肌肉的血氧饱和度，但90%（22头中的20头）需要血管加压药支持。使用任何一种血管加压药6小时后，血流动力学稳定。然而，与精氨酸加压素相比，使用去氧肾上腺素时，颅内压平均高出>10毫米汞柱，脑组织氧分压低6毫米汞柱，而肩部和后肢肌肉的组织血氧饱和度高出>10%（所有p<0.05）。
精氨酸加压素在维持脑灌注压方面与去氧肾上腺素效果相当，但颅内压和脑组织氧合的改善是以牺牲外周为代价的。
