患有预先存在的非心源性肺动脉高压的患者中的严重脓毒症和脓毒性休克：当代管理和结局。

Severe sepsis and septic shock in patients with pre-existing non-cardiac pulmonary hypertension: contemporary management and outcomes.

机构信息

Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA.

出版信息

Crit Care Resusc. 2013 Jun;15(2):103-9.

Abstract

OBJECTIVE

To review treatment and outcomes of septic shock in patients with pulmonary hypertension (PH) managed at a tertiary care institution.

DESIGN, SETTING AND PATIENTS: We identified consecutive patients with non-cardiac PH (non-Group 2 in the World Health Organization classification) who were treated for septic shock in four intensive care units at a tertiary care institution between July 2004 and July 2007. Patients with a left ventricular ejection fraction < 50%, diastolic dysfunction, pericardial effusion or significant valve disease were excluded. Descriptive statistics were used to analyse the data.

MAIN OUTCOME MEASURES

Hospital mortality, duration of vasopressor and ventilatory support, length of hospital and ICU stay.

RESULTS

The final group for analysis comprised 82 patients. The major causes of PH were chronic obstructive pulmonary disease, interstitial lung disease and portopulmonary hypertension. PH was mild in 46 patients (56%), moderate in 21 (26%) and severe in 15 (18%). Vasopressor treatment was initiated in 69 patients (84%) within the first 48 hours: noradrenaline was most commonly used (53 patients, 65%), and 51 patients (62%) were treated with more than one agent. Sixty-seven patients (82%) were mechanically ventilated, and 33 (40%) required renal replacement therapy. Fortythree patients (52%) survived to hospital discharge; 23 (28%) remained alive at 1 year. Hospital mortality increased with severity of PH: 28% in mild, 67% in moderate and 80% in severe PH. Nonsurvivors were more likely to have plateau pressures beyond 30 cm H(2)O while mechanically ventilated within the first 48 hours in the ICU (56% v 29%, P = 0.03), to develop atrial fibrillation (AF) (46% v 12%, P < 0.001), and to require longer vasopressor support (mean, 5.3 v 2.6 days, P = 0.003). In a multivariate logistic regression analysis, severity of PH (odds ratio [OR], 1.55; 95% CI, 1.04-2.46; P = 0.04), new-onset AF (OR, 6.51; 95% CI, 2.24-22.07; P < 0.001) and longer duration of vasopressor support (OR, 1.15; 95% CI, 1.03-1.34; P = 0.04) were associated with increased hospital mortality.

CONCLUSIONS

The severity of PH, new-onset AF, and longer vasopressor support were associated with poor outcomes in patients with PH who developed severe sepsis and septic shock.

摘要

目的

回顾在一家三级保健机构治疗的肺动脉高压（PH）患者并发感染性休克的治疗和结果。

设计、地点和患者：我们在 2004 年 7 月至 2007 年 7 月期间，在一家三级保健机构的四个重症监护病房中，连续确定了患有非心源性 PH（世界卫生组织分类中的非 2 组）且接受感染性休克治疗的患者。排除左心室射血分数 <50%、舒张功能障碍、心包积液或严重瓣膜疾病的患者。使用描述性统计分析数据。

主要观察指标

住院死亡率、血管加压素和通气支持时间、住院和 ICU 住院时间。

结果

最终分析的组包括 82 名患者。PH 的主要病因是慢性阻塞性肺疾病、间质性肺疾病和门肺高压。46 名患者（56%）为轻度 PH，21 名（26%）为中度 PH，15 名（18%）为重度 PH。血管加压素治疗在 48 小时内开始在 69 名患者（84%）中使用：最常使用去甲肾上腺素（53 名患者，65%），51 名患者（62%）使用了一种以上的药物。67 名患者（82%）接受机械通气，33 名（40%）需要肾脏替代治疗。43 名患者（52%）存活至出院；23 名（28%）在 1 年后仍存活。PH 严重程度与住院死亡率增加相关：轻度为 28%，中度为 67%，重度为 80%。非幸存者在 ICU 内机械通气的最初 48 小时内，平台压超过 30 cm H2O 的可能性更大（56%比 29%，P = 0.03），更易发生心房颤动（AF）（46%比 12%，P < 0.001），需要更长时间的血管加压素支持（平均 5.3 天比 2.6 天，P = 0.003）。在多变量逻辑回归分析中，PH 严重程度（比值比 [OR]，1.55；95%置信区间，1.04-2.46；P = 0.04）、新发房颤（OR，6.51；95%置信区间，2.24-22.07；P < 0.001）和血管加压素支持时间延长（OR，1.15；95%置信区间，1.03-1.34；P = 0.04）与 PH 患者发生严重脓毒症和感染性休克后的住院死亡率增加相关。