Critical Care, Department of Pharmacy, Seton Healthcare Family, Austin, TX, USA.
Ann Pharmacother. 2013 Mar;47(3):301-10. doi: 10.1345/aph.1R442. Epub 2013 Feb 27.
Early goal-directed therapy is a time-sensitive therapeutic algorithm with a tiered approach to target hypoperfusion and cardiovascular collapse within the first 6 hours of septic shock. The Surviving Sepsis Campaign guidelines recommend norepinephrine or dopamine as the initial vasoactive agent for resuscitation in septic shock, reserving the administration of vasopressin as adjunctive therapy.
To determine whether vasopressin was noninferior to norepinephrine as the initial vasopressor to achieve a mean arterial pressure (MAP) goal in the first 6 hours of shock onset.
This retrospective cohort study evaluated adults who received monotherapy with either norepinephrine or vasopressin as initial vasoactive therapy for the management of septic shock. Patients were excluded if the treatment arm was not monotherapy, if they were admitted to a cardiology or cardiothoracic surgery service, or if they lacked a comparator-based 1:1 frequency matching.
A total of 130 patients were included, 65 in each treatment arm. The proportion of patients who achieved a goal MAP in the vasopressin group was 63% (95% CI 51%-75%) and was 67.7% (95% CI 56%-79%) in the norepinephrine group. This observed difference between goal MAP attainment did not exceed the predefined noninferiority margin of -25% (CI for 4.7% difference -21.2% to 12%), suggesting noninferiority of vasopressin. No significant difference was identified between vasopressin and norepinephrine for final mean (SD) MAP achieved (75 [9.6] and 76.0 [8.2] mm Hg, respectively; p = 0.06) or the mean total change from baseline MAP to goal (14.1 [8.4] and 15.1 [9.1] mm Hg, respectively; p = 0.6).
Vasopressin was noninferior to norepinephrine for the achievement of a MAP goal in the first 6 hours from onset of septic shock. Further prospective analysis is warranted; however, the results are useful for consideration of alternative vasopressors in the setting of drug shortages.
早期目标导向治疗是一种时间敏感的治疗算法，采用分层方法在脓毒性休克的最初 6 小时内针对低灌注和心血管崩溃。《拯救脓毒症运动指南》建议去甲肾上腺素或多巴胺作为脓毒性休克复苏的初始血管活性药物，将血管加压素作为辅助治疗保留。
确定血管加压素是否作为初始升压药与去甲肾上腺素一样能在休克发作的最初 6 小时内达到平均动脉压（MAP）目标。
本回顾性队列研究评估了接受去甲肾上腺素或血管加压素单药治疗作为脓毒性休克管理初始血管活性治疗的成年人。如果治疗臂不是单药治疗，如果他们被收住在心脏病学或心胸外科服务，如果他们缺乏基于比较器的 1:1 频率匹配，则将患者排除在外。
共纳入 130 例患者，每组 65 例。血管加压素组达到目标 MAP 的患者比例为 63%（95%CI 51%-75%），去甲肾上腺素组为 67.7%（95%CI 56%-79%）。观察到的目标 MAP 达标差异未超过预设的非劣效性边界-25%（差异的 95%CI 为-21.2%至 12%），提示血管加压素非劣效。血管加压素与去甲肾上腺素在最终平均（SD）MAP 达到（分别为 75[9.6]和 76.0[8.2]mmHg；p=0.06）或从基线 MAP 到目标的平均总变化（分别为 14.1[8.4]和 15.1[9.1]mmHg；p=0.6）方面均无显著差异。
血管加压素在脓毒性休克发作后的最初 6 小时内达到 MAP 目标的非劣效性优于去甲肾上腺素。需要进一步进行前瞻性分析；然而，这些结果对于在药物短缺的情况下考虑替代血管加压素是有用的。
