D'Aragon Frederick, Belley-Cote Emilie P, Meade Maureen O, Lauzier François, Adhikari Neill K J, Briel Matthias, Lalu Manoj, Kanji Salmaan, Asfar Pierre, Turgeon Alexis F, Fox-Robichaud Alison, Marshall John C, Lamontagne François
*Department of Anaesthesia, Division of Critical Care, McMaster University; and †Departments of Medicine, and Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario; ‡Centre Hospitalier Universitaire de Québec Research Center, Population Health and Optimal Health Practices, Division of Critical Care Medicine, Department of Anesthesiology, Department of Medicine, Université Laval, Québec, Québec; and §Department of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada; ∥Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland; ¶Department of Anesthesiology, University of Ottawa, and **Department of Pharmacy, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada; ††Département de Réanimation Médicale et de Médecine Hyperbare, Centre Hospitalier Universitaire Angers, Angers, France; ‡‡Centre Hospitalier Universitaire de Québec Research Center, Population Health and Optimal Health Practices, Division of Critical Care Medicine, Department of Anesthesiology, Université Laval, Québec, Québec; §§Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton; and ∥∥Li Ka Shing Knowledge Institute, St. Michaels Hospital, University of Toronto, Toronto, Ontario; and ¶¶Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Département de médicine, Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Québec, Canada.
Shock. 2015 Jun;43(6):530-9. doi: 10.1097/SHK.0000000000000348.
Physicians often prescribe vasopressors to correct pathological vasodilation and improve tissue perfusion in patients with septic shock, but the evidence to inform practice on vasopressor dosing is weak. We undertook a systematic review of clinical studies evaluating different blood pressure targets for the dosing of vasopressors in septic shock. We searched MEDLINE, EMBASE, CENTRAL (to November 2013), reference lists from included articles, and trial registries for randomized controlled trials (RCTs) and observational and crossover intervention studies comparing different blood pressure targets for vasopressor therapy in septic shock. Two reviewers independently selected eligible studies and extracted data on standardized forms. We identified 2 RCTs and 10 crossover trials but no observational studies meeting our criteria. Only one RCT measured clinical outcomes after comparing mean arterial pressure targets of 80 to 85 mmHg versus 65 to 70 mmHg. There was no effect on 28-day mortality, but confidence intervals were wide (hazard ratio, 95% confidence interval [95% CI] 0.84 - 1.38). In contrast, this intervention was associated with a greater risk of atrial fibrillation (relative risk, 2.36; 95% CI, 1.18 - 4.72) and a lower risk of renal replacement therapy in hypertensive patients (relative risk, 0.75; 95% CI, 0.57 - 1.0). Crossover trials suggest that achieving higher blood pressure targets by increasing vasopressor doses increases heart rate and cardiac index with no effect on serum lactate. Our findings underscore the paucity of clinical evidence to guide the administration of vasopressors in critically ill patients with septic shock. Further rigorous research is needed to establish an evidence base for vasopressor administration in this population.
医生经常开具血管升压药来纠正病理性血管舒张，并改善感染性休克患者的组织灌注，但关于血管升压药给药剂量的实践证据并不充分。我们对评估感染性休克中血管升压药不同血压目标剂量的临床研究进行了系统综述。我们检索了MEDLINE、EMBASE、CENTRAL（截至2013年11月）、纳入文章的参考文献列表以及试验注册库，以查找比较感染性休克中血管升压药治疗不同血压目标的随机对照试验（RCT）、观察性研究和交叉干预研究。两名评审员独立选择符合条件的研究，并在标准化表格上提取数据。我们确定了2项RCT和10项交叉试验，但没有符合我们标准的观察性研究。只有一项RCT在比较平均动脉压目标为80至85 mmHg与65至70 mmHg后测量了临床结局。对28天死亡率没有影响，但置信区间较宽（风险比，95%置信区间[95%CI] 0.84 - 1.38）。相比之下，这种干预与房颤风险增加（相对风险，2.36；95%CI，1.18 - 4.72）以及高血压患者接受肾脏替代治疗的风险降低（相对风险，0.75；95%CI，0.57 - 1.0）相关。交叉试验表明，通过增加血管升压药剂量实现更高的血压目标会增加心率和心脏指数，而对血清乳酸没有影响。我们的研究结果强调了指导感染性休克重症患者使用血管升压药的临床证据匮乏。需要进一步进行严谨的研究，以建立该人群血管升压药给药的证据基础。
