Redl-Wenzl E M, Armbruster C, Edelmann G, Fischl E, Kolacny M, Wechsler-Fördös A, Sporn P
Institut für Anaesthesiologie, Krankenanstalt Rudolfstiftung, Wien.
Anaesthesist. 1990 Oct;39(10):525-9.
We investigated the impact of norepinephrine administration on hemodynamics, oxygen metabolism and renal function in patients in severe septic shock. PATIENTS AND METHODS. Twenty-six patients with extremely low resistance who were between 24 and 87 years of age were included in the study. In 7 patients, acute necrotizing pancreatitis and superinfection was diagnosed; 19 patients suffered from diffuse peritonitis. The entrance criteria for the study were: a mean arterial pressure (MAP) of below 60 torr or, in chronic hypertensive patients, a decrease in systolic pressure of more than 50 torr compared to previous values, despite volume optimization, and dopamine greater than 20 micrograms/kg per min and cumulative doses of dopamine/dobutamine greater than 30 micrograms/kg per min, respectively. Cases with tachycardia greater than 140/min were also included in the study even when the inotropic medication dose was lower. After registration of baseline values, dopamine was reduced to 2.5 micrograms/kg per min, and norepinephrine was administered starting at a dose rate of 0.05 micrograms/kg per min, until a MAP of greater than 60 torr could be maintained. RESULTS. Of the 26 patients investigated, 16 survived; 10 patients with persisting sepsis died due to multiple organ failure (mortality: 38.5%). During the study period, a norepinephrine dosage ranging between 0.1 and 2 micrograms/kg per min was necessary to stabilize the arterial pressure. The mean dose rate was 0.3 micrograms/kg per min. The mean arterial pressure and systemic vascular resistance index showed a statistically significant increase of 30 and 20%, respectively, just after 1 h and distinctly remained above the initial values in the further course. The cardiac index remained constant or increased slightly. After 24 h a statistically significant increase in stroke volume and a decrease in heart rate could be observed. Creatinine clearance increased significantly from the control value of 73 +/- 48 ml/min to 114 +/- 37 ml/min after 48 h under norepinephrine treatment. O2-delivery and O2-consumption did not change significantly, although they showed a slight tendency to increase. CONCLUSION. When patients are in a septic high output-low resistance condition, particular attention must be paid to maintaining sufficient mean arterial pressures. Our results suggest that this essential goal can be achieved by norepinephrine. The mean arterial pressure and glomerular filtration rate improved markedly, and there was no evidence of bad effects such as an increased afterload on critical parameters like cardiac index, O2-delivery and O2-consumption.
我们研究了去甲肾上腺素给药对严重感染性休克患者血流动力学、氧代谢和肾功能的影响。患者与方法。本研究纳入了26例年龄在24至87岁之间、抵抗力极低的患者。其中7例诊断为急性坏死性胰腺炎并伴有超级感染；19例患有弥漫性腹膜炎。本研究的入选标准为：平均动脉压（MAP）低于60托，或者对于慢性高血压患者，与先前值相比收缩压下降超过50托，尽管已进行容量优化，且多巴胺剂量大于20微克/千克每分钟，多巴胺/多巴酚丁胺累积剂量分别大于30微克/千克每分钟。即使在强心药物剂量较低时，心率大于140次/分钟的病例也纳入本研究。记录基线值后，将多巴胺降至2.5微克/千克每分钟，并开始以0.05微克/千克每分钟的剂量率给予去甲肾上腺素，直至能维持MAP大于60托。结果。在研究的26例患者中，16例存活；10例持续性脓毒症患者因多器官功能衰竭死亡（死亡率：38.5%）。在研究期间，需要0.1至2微克/千克每分钟的去甲肾上腺素剂量来稳定动脉压。平均剂量率为0.3微克/千克每分钟。平均动脉压和全身血管阻力指数在1小时后分别有统计学意义地升高了30%和20%，并且在后续过程中明显保持高于初始值。心脏指数保持不变或略有增加。24小时后可观察到每搏输出量有统计学意义地增加，心率下降。在去甲肾上腺素治疗48小时后，肌酐清除率从对照值73±48毫升/分钟显著增加至114±37毫升/分钟。氧输送和氧消耗虽有轻微增加趋势，但无显著变化。结论。当患者处于感染性高输出 - 低阻力状态时，必须特别注意维持足够的平均动脉压。我们的结果表明，去甲肾上腺素可实现这一重要目标。平均动脉压和肾小球滤过率显著改善，且未发现对心脏指数、氧输送和氧消耗等关键参数有诸如后负荷增加等不良影响。
