Department of Intensive Care Medicine, Bern University Hospital (Inselspital) and University of Bern, Bern, Switzerland.
Crit Care Med. 2010 Oct;38(10 Suppl):S613-9. doi: 10.1097/CCM.0b013e3181f2430c.
To review blood pressure targets and their implementation in sepsis.
Review of the hemodynamic intervention trials in sepsis.
Explicit blood pressure targets have been recommended for septic patients. The Surviving Sepsis Guidelines recommend vasopressors to achieve and maintain a mean arterial blood pressure of at least 65 mm Hg in patients not responding to initial fluid resuscitation. Patients remaining hypotensive despite efforts to increase blood pressure have up to twice as high mortality as those whose hypotension can be corrected with fluids and vasopressors. The actual blood pressure targets and their implementation are the main determinants of the patient's exposure to vasopressors. Several randomized controlled trials on hemodynamic interventions in septic shock show that patients continue to receive vasopressors despite the fact that blood pressure targets have been exceeded, and thus vasopressors should be reduced. Accordingly, patients are likely to be exposed to higher amounts of vasopressors and over longer periods of time than would be necessary if the predefined targets would be strictly implemented. Post hoc analyses suggest that in patients without refractory hypotension, the cumulative vasopressor load is independently associated with mortality. Accordingly, reduction of exposure to vasopressors has the potential of improving outcomes. This can be achieved by adhering to the lower currently proposed blood pressure limits. In addition, the lowest tolerable blood pressure levels should be reevaluated.
综述脓毒症血压目标及其实施情况。
脓毒症血流动力学干预试验的综述。
明确推荐了脓毒症患者的血压目标。《拯救脓毒症运动指南》建议，对于初始液体复苏后无反应的患者，使用升压药以达到并维持平均动脉压至少 65mmHg。与低血压可通过液体和升压药纠正的患者相比，尽管努力升高血压但仍低血压的患者死亡率高达其两倍。实际血压目标及其实施是患者接受升压药治疗的主要决定因素。几项关于脓毒性休克血流动力学干预的随机对照试验表明，尽管已经超过了血压目标，但患者仍继续接受升压药治疗，因此应减少升压药的使用。因此，如果严格实施预设目标，患者可能会暴露于更高剂量的升压药并接受更长时间的治疗。事后分析表明，在无难治性低血压的患者中，累积升压药负荷与死亡率独立相关。因此，减少升压药的暴露有改善预后的潜力。这可以通过遵循目前提出的较低血压限制来实现。此外，应重新评估最低可耐受的血压水平。
