Weiss P, Schmidlin O, Ha H R, Ritz R, Follath F
Abteilungen für Klinische Pharmacokologie und Intensivmedizin, Kantonsspital Basel.
Schweiz Med Wochenschr. 1990 Feb 10;120(6):190-3.
The feasibility of heart transplantation has stimulated new interest in the therapy of severe refractory congestive heart failure even as an interim solution. We studied the hemodynamics, clinical efficacy and practical implications of a 72-hour dobutamine infusion in 11 patients with NYHA IV refractory congestive heart failure (age 40-73, average 55 years). The dose was 250-1000 micrograms/min, with the goal of increasing cardiac output by 30-50%. Changes in the pharmacokinetics of lidocaine were studied by single dose kinetics in 7 patients. Cardiac output increased from 2.94 +/- 0.68 to 4.77 +/- 1.1 l/min and stroke volume from 35 +/- 10 to 56 +/- 12 ml (p less than 0.001). Pulmonary capillary wedge pressure decreased from 28.5 +/- 5 to 21 +/- 6 and central venous pressure from 14 +/- 6 to 7 +/- 3 mm Hg (p less than 0.007). There was marked worsening of hemodynamics 24-48 h after starting dobutamine. However, after withdrawal of dobutamine a significantly higher cardiac output and stroke volume (3.73 +/- 0.43 l/min, 42 +/- 7 mm Hg. p less than 0.05) persisted. Both clearance and distribution volume of lidocaine increased, while half life decreased significantly (6.61 +/- 1.43 to 5.33 +/- 0.77 h. p less than 0.05). 9 of 11 patients developed Lown IVb ventricular arrhythmia, while in 4 massive diuresis occurred necessitating volume substitution. 6 patients left hospital clinically improved, 2 were transplanted and 3 patients died 1 day to 3 weeks after ending dobutamine. Dobutamine had salutary hemodynamic and clinical effects outlasting the duration of dobutamine therapy. Due to its arrhythmogenic effects it should be administered under ECG monitoring. In patients treated with lidocaine, upward dose adjustments may be necessary with improving hemodynamics.
心脏移植的可行性激发了人们对严重难治性充血性心力衰竭治疗的新兴趣，即使作为一种临时解决方案。我们研究了11例纽约心脏协会（NYHA）IV级难治性充血性心力衰竭患者（年龄40 - 73岁，平均55岁）静脉输注多巴酚丁胺72小时后的血流动力学、临床疗效及实际影响。剂量为250 - 1000微克/分钟，目标是使心输出量增加30 - 50%。通过单剂量动力学研究了7例患者利多卡因药代动力学的变化。心输出量从2.94±0.68升/分钟增加到4.77±1.1升/分钟，每搏输出量从35±10毫升增加到56±12毫升（p<0.001）。肺毛细血管楔压从28.5±5降至21±6，中心静脉压从14±6降至7±3毫米汞柱（p<0.007）。开始使用多巴酚丁胺后24 - 48小时血流动力学明显恶化。然而，停用多巴酚丁胺后，心输出量和每搏输出量仍显著较高（3.73±0.43升/分钟，42±7毫米汞柱，p<0.05）。利多卡因的清除率和分布容积均增加，而半衰期显著缩短（从6.61±1.43小时降至5.33±0.77小时，p<0.05）。11例患者中有9例出现了洛恩IVb级室性心律失常，4例出现大量利尿，需要补充容量。6例患者临床症状改善出院，2例接受了心脏移植，3例患者在多巴酚丁胺治疗结束后1天至3周死亡。多巴酚丁胺具有有益的血流动力学和临床效果，且持续时间超过多巴酚丁胺治疗期。由于其致心律失常作用，应在心电图监测下给药。在使用利多卡因治疗的患者中，随着血流动力学改善可能需要向上调整剂量。
