Department of Critical Care, National Heart and Lung Institute, Imperial College London, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK.
Crit Care. 2010;14(5):R169. doi: 10.1186/cc9264. Epub 2010 Sep 21.
Pulmonary vascular dysfunction, pulmonary hypertension (PH), and resulting right ventricular (RV) failure occur in many critical illnesses and may be associated with a worse prognosis. PH and RV failure may be difficult to manage: principles include maintenance of appropriate RV preload, augmentation of RV function, and reduction of RV afterload by lowering pulmonary vascular resistance (PVR). We therefore provide a detailed update on the management of PH and RV failure in adult critical care.
A systematic review was performed, based on a search of the literature from 1980 to 2010, by using prespecified search terms. Relevant studies were subjected to analysis based on the GRADE method.
Clinical studies of intensive care management of pulmonary vascular dysfunction were identified, describing volume therapy, vasopressors, sympathetic inotropes, inodilators, levosimendan, pulmonary vasodilators, and mechanical devices. The following GRADE recommendations (evidence level) are made in patients with pulmonary vascular dysfunction: 1) A weak recommendation (very-low-quality evidence) is made that close monitoring of the RV is advised as volume loading may worsen RV performance; 2) A weak recommendation (low-quality evidence) is made that low-dose norepinephrine is an effective pressor in these patients; and that 3) low-dose vasopressin may be useful to manage patients with resistant vasodilatory shock. 4) A weak recommendation (low-moderate quality evidence) is made that low-dose dobutamine improves RV function in pulmonary vascular dysfunction. 5) A strong recommendation (moderate-quality evidence) is made that phosphodiesterase type III inhibitors reduce PVR and improve RV function, although hypotension is frequent. 6) A weak recommendation (low-quality evidence) is made that levosimendan may be useful for short-term improvements in RV performance. 7) A strong recommendation (moderate-quality evidence) is made that pulmonary vasodilators reduce PVR and improve RV function, notably in pulmonary vascular dysfunction after cardiac surgery, and that the side-effect profile is reduced by using inhaled rather than systemic agents. 8) A weak recommendation (very-low-quality evidence) is made that mechanical therapies may be useful rescue therapies in some settings of pulmonary vascular dysfunction awaiting definitive therapy.
This systematic review highlights that although some recommendations can be made to guide the critical care management of pulmonary vascular and right ventricular dysfunction, within the limitations of this review and the GRADE methodology, the quality of the evidence base is generally low, and further high-quality research is needed.
在许多危重病中会发生肺血管功能障碍、肺动脉高压（PH）和由此导致的右心室（RV）衰竭，并且可能与预后较差相关。PH 和 RV 衰竭可能难以治疗：原则包括维持适当的 RV 前负荷、增强 RV 功能以及通过降低肺血管阻力（PVR）来减少 RV 后负荷。因此，我们提供了关于成人危重病中 PH 和 RV 衰竭管理的详细更新。
基于 1980 年至 2010 年的文献检索，进行了系统评价，并使用了预设的检索词。根据 GRADE 方法对相关研究进行了分析。
确定了关于肺血管功能障碍的重症监护管理的临床研究，描述了容量治疗、血管加压药、拟交感神经正性肌力药、正性肌力血管扩张剂、左西孟旦、肺血管扩张剂和机械装置。对肺血管功能障碍患者做出以下 GRADE 推荐（证据水平）：1）弱推荐（极低质量证据）建议密切监测 RV，因为容量负荷可能会使 RV 功能恶化；2）弱推荐（低质量证据）建议在这些患者中使用低剂量去甲肾上腺素作为有效的升压药；3）弱推荐（低质量证据）建议低剂量血管加压素可能有助于治疗血管扩张性休克患者；4）弱推荐（低中度质量证据）建议低剂量多巴酚丁胺可改善肺血管功能障碍患者的 RV 功能；5）强推荐（中度质量证据）建议磷酸二酯酶 3 抑制剂可降低 PVR 并改善 RV 功能，尽管低血压较为常见；6）弱推荐（低质量证据）建议左西孟旦可能对 RV 性能的短期改善有用；7）强推荐（中度质量证据）建议肺血管扩张剂可降低 PVR 并改善 RV 功能，特别是在心脏手术后的肺血管功能障碍中，并且通过使用吸入而不是全身药物可降低副作用谱；8）弱推荐（极低质量证据）建议在等待确定性治疗的情况下，机械疗法可能是肺血管功能障碍某些情况下的有用抢救疗法。
本系统评价强调，尽管可以提出一些建议来指导肺血管和右心室功能障碍的重症监护管理，但在本综述和 GRADE 方法的局限性内，证据基础的质量通常较低，需要进一步进行高质量的研究。
