Piton Gaël, Cypriani Benoit, Regnard Jacques, Patry Cyrille, Puyraveau Marc, Capellier Gilles
*Medical Intensive Care Unit, University Hospital, Besançon, France, †Research Unit EA 3920 and SFR FED 4234, University of Franche Comté, Besançon, France, ‡Clinical Chemistry Unit, §Physiology Department, ∥Clinical Methodology Center, University Hospital, Besançon, France; and ¶Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences, Clayton, Australia.
Shock. 2015 May;43(5):437-42. doi: 10.1097/SHK.0000000000000327.
Small bowel damage is frequent but underdiagnosed among critically ill patients with shock. High catecholamine doses may have a deleterious effect on mesenteric blood flow. Plasma intestinal fatty acid-binding protein (I-FABP) concentration is a marker of enterocyte damage, whereas plasma citrulline concentration is a marker of functional enterocyte mass. We hypothesized that high doses of catecholamines in critically ill patients may be associated with enterocyte damage. This study aimed to determine the link between catecholamine use and dose with enterocyte damage. This is a prospective observational study performed in a large regional university teaching hospital. Critically ill patients requiring epinephrine and/or norepinephrine at admission to a medical intensive care unit (ICU) were included, as well as controls not receiving catecholamines. We evaluated at admission plasma I-FABP and citrulline concentrations, abdominal perfusion pressure (APP), and variables relating to prognosis and treatment. Patients were categorized according to the quartiles of catecholamine dose at ICU admission. Sixty critically ill patients receiving catecholamines and 27 not receiving catecholamines were included. Plasma I-FABP was higher among patients receiving catecholamine than in controls. Among patients receiving catecholamines, a dose of 0.48 γ kg min or more at ICU admission was associated with a higher I-FABP concentration. A Sepsis-related Organ Failure Assessment score higher than 11 and plasma I-FABP more than 524 pg mL at ICU admission were independently associated with 28-day mortality (odds ratio, 4.0 [1.24-12.95] and odds ratio, 4.90 [1.44-16.6], respectively). Catecholamine use is associated with I-FABP elevation in critically ill patients. Critically ill patients receiving more than 0.48 γ kg min of epinephrine and/or norepinephrine at ICU admission have high I-FABP concentrations. This suggests that enterocyte damage reflects the severity of shock, and an adverse effect of catecholamines per se is possible.
在重症休克患者中，小肠损伤很常见，但却常常被漏诊。高剂量儿茶酚胺可能会对肠系膜血流产生有害影响。血浆肠脂肪酸结合蛋白（I-FABP）浓度是肠细胞损伤的标志物，而血浆瓜氨酸浓度是功能性肠细胞数量的标志物。我们推测，重症患者使用高剂量儿茶酚胺可能与肠细胞损伤有关。本研究旨在确定儿茶酚胺的使用及剂量与肠细胞损伤之间的联系。这是一项在大型地区性大学教学医院进行的前瞻性观察性研究。纳入了入住医疗重症监护病房（ICU）时需要肾上腺素和/或去甲肾上腺素的重症患者，以及未接受儿茶酚胺治疗的对照组。我们在入院时评估了血浆I-FABP和瓜氨酸浓度、腹部灌注压（APP）以及与预后和治疗相关的变量。根据患者入住ICU时儿茶酚胺剂量的四分位数对患者进行分类。共纳入60例接受儿茶酚胺治疗的重症患者和27例未接受儿茶酚胺治疗的患者。接受儿茶酚胺治疗的患者血浆I-FABP高于对照组。在接受儿茶酚胺治疗的患者中，入住ICU时剂量达到或超过0.48 μg/kg·min与更高的I-FABP浓度相关。入住ICU时脓毒症相关器官功能衰竭评估（SOFA）评分高于11分以及血浆I-FABP超过524 pg/mL与28天死亡率独立相关（优势比分别为4.0[1.24 - 12.95]和4.90[1.44 - 16.6]）。在重症患者中，使用儿茶酚胺与I-FABP升高有关。入住ICU时接受肾上腺素和/或去甲肾上腺素剂量超过0.48 μg/kg·min的重症患者I-FABP浓度较高。这表明肠细胞损伤反映了休克的严重程度，儿茶酚胺本身可能存在不良影响。
