Service de Réanimation Médicale, CHU Nancy-Brabois, Vandoeuvre les Nancy, France.
Crit Care Med. 2011 Mar;39(3):450-5. doi: 10.1097/CCM.0b013e3181ffe0eb.
There is no study that has compared, in a randomized manner, which vasopressor is most suitable in optimizing both systemic and regional hemodynamics in cardiogenic shock patients. Hence, the present study was designed to compare epinephrine and norepinephrine-dobutamine in dopamine-resistant cardiogenic shock.
Open, randomized interventional human study.
Medical intensive care unit in a university hospital.
Thirty patients with a cardiac index of <2.2 L/min/m and a mean arterial pressure of <60 mm Hg resistant to combined dopamine-dobutamine treatment and signs of shock. Patients were not included in cases of cardiogenic shock secondary to acute ischemic events such as myocardial infarction. Noninclusion criteria also included immediate indication of mechanical assistance.
Patients were randomized to receive an infusion of either norepinephrine-dobutamine or epinephrine titrated to obtain a mean arterial pressure of between 65 and 70 mm Hg with a stable or increased cardiac index.
Both regimens increased cardiac index and oxygen-derived parameters in a similar manner. Patients in the norepinephrine-dobutamine group demonstrated heart rates lower (p<.05) than those in the epinephrine group. Epinephrine infusion was associated with new arrhythmias in three patients. When compared to baseline values, after 6 hrs, epinephrine infusion was associated with an increase in lactate level (p<.01), whereas this level decreased in the norepinephrine-dobutamine group. Tonometered PCO2 gap, a surrogate for splanchnic perfusion adequacy, increased in the epinephrine-treated group (p<.01) while decreasing in the norepinephrine group (p<.01). Diuresis increased in both groups but significantly more so in the norepinephrine-dobutamine group, whereas plasma creatinine decreased in both groups.
When considering global hemodynamic effects, epinephrine is as effective as norepinephrine-dobutamine. Nevertheless, epinephrine is associated with a transient lactic acidosis, higher heart rate and arrhythmia, and inadequate gastric mucosa perfusion. Thus, the combination norepinephrine-dobutamine appears to be a more reliable and safer strategy.
目前尚无研究以随机方式比较哪种血管加压药最适合优化心源休克患者的全身和局部血液动力学。因此，本研究旨在比较去甲肾上腺素和肾上腺素-多巴酚丁胺在多巴胺抵抗性心源休克中的作用。
开放、随机干预性人体研究。
大学医院的重症监护病房。
30 例心指数<2.2L/min/m且平均动脉压<60mmHg 的患者，这些患者对多巴胺-多巴酚丁胺联合治疗有抵抗作用且有休克表现。未将继发于急性缺血事件（如心肌梗死）的心源休克患者纳入本研究。排除标准还包括立即需要机械辅助的情况。
患者随机接受去甲肾上腺素-多巴酚丁胺或肾上腺素输注，以将平均动脉压滴定至 65-70mmHg，同时保持或增加心指数。
两种方案均以相似的方式增加心指数和氧衍生参数。去甲肾上腺素-多巴酚丁胺组的心率低于（p<0.05）肾上腺素组。肾上腺素输注引起 3 例新出现心律失常。与基线值相比，输注肾上腺素 6 小时后，乳酸水平升高（p<0.01），而去甲肾上腺素-多巴酚丁胺组的乳酸水平降低。作为内脏灌注充足的替代指标，经皮二氧化碳分压间隙在接受肾上腺素治疗的组中增加（p<0.01），而在去甲肾上腺素组中降低（p<0.01）。两组的尿量均增加，但去甲肾上腺素-多巴酚丁胺组增加更明显，而两组的血浆肌酐均降低。
就整体血液动力学效应而言，肾上腺素与去甲肾上腺素-多巴酚丁胺同样有效。然而，肾上腺素与一过性乳酸酸中毒、更高的心率和心律失常以及内脏黏膜灌注不足相关。因此，去甲肾上腺素-多巴酚丁胺联合用药似乎是一种更可靠和更安全的策略。
