Brand Donald A, Patrick Patricia A, Berger Jeffrey T, Ibrahim Mediha, Matela Ajsza, Upadhyay Shweta, Spiegler Peter
Office of Health Outcomes Research, Winthrop University Hospital, Mineola, New York, USA; School of Medicine, Stony Brook University, Stony Brook, New York, USA.
Westchester Institute for Human Development, Valhalla, New York, USA; School of Health Sciences and Practice, New York Medical College, Valhalla, New York, USA.
J Pain Symptom Manage. 2017 May;53(5):938-943. doi: 10.1016/j.jpainsymman.2016.12.333. Epub 2017 Jan 3.
Given the high mortality of 30%-60% associated with septic shock, distinguishing which patients do or do not have a reasonable chance of surviving with aggressive treatment could help clinicians and families make informed decisions.
To determine if intensity of vasopressor therapy accurately predicts in-hospital death.
This observational cohort study analyzed in-hospital mortality as a function of intensity of vasopressor therapy in a consecutive series of adults with septic shock treated over a four-year period. Receiver operating characteristic curve analysis assessed the overall strength of the intensity-mortality relationship.
A total of 808 patients with septic shock experienced an in-hospital death rate of 41.0% (331/808; 95% CI, 38.5%-44.5%). The greater the peak number of vasopressors required, the higher the death rate, which reached 92.3% (12/13; 95% CI, 79.4%-100.0%) when three different pressors were being infused at full dose. The receiver operating characteristic curve analysis revealed that number of simultaneous vasopressors and vasopressor dose load performed equally well in predicting death or survival.
When a standard full dose of a vasopressor fails to normalize blood pressure in a patient with septic shock, escalation begins to yield diminishing returns as the dose and multiplicity of agents approach practical upper limits. Although it is not possible to specify a precise cutoff for limiting vs. intensifying therapy, a mortality of 80% or higher-characterized by two or more concurrent vasopressors at full dose-should prompt shared decision making with the patient's family.
鉴于脓毒性休克的死亡率高达30%-60%，区分哪些患者通过积极治疗有合理的存活机会，哪些没有，这有助于临床医生和患者家属做出明智的决策。
确定血管升压药治疗强度能否准确预测住院死亡率。
这项观察性队列研究分析了在四年期间连续治疗的一系列成年脓毒性休克患者的住院死亡率与血管升压药治疗强度之间的关系。受试者工作特征曲线分析评估了强度-死亡率关系的总体强度。
共有808例脓毒性休克患者，住院死亡率为41.0%（331/808；95%CI，38.5%-44.5%）。所需血管升压药的峰值数量越多，死亡率越高，当三种不同的升压药全剂量输注时，死亡率达到92.3%（12/13；95%CI，79.4%-100.0%）。受试者工作特征曲线分析显示，同时使用的血管升压药数量和血管升压药剂量负荷在预测死亡或存活方面表现相当。
当标准全剂量的血管升压药未能使脓毒性休克患者的血压恢复正常时，随着药物剂量和种类接近实际上限，增加剂量开始产生递减的收益。虽然不可能指定一个精确的界限来区分是限制治疗还是强化治疗，但死亡率达到80%或更高（以两种或更多同时全剂量使用的血管升压药为特征）时，应促使与患者家属共同做出决策。
