Nagendran Myura, Maruthappu Mahiben, Gordon Anthony C, Gurusamy Kurinchi S
Section of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, London, UK.
North West Thames Foundation School, Imperial College London, London, UK.
J Intensive Care Soc. 2016 May;17(2):136-145. doi: 10.1177/1751143715620203. Epub 2015 Dec 17.
Septic shock is a life-threatening condition requiring vasopressor agents to support the circulatory system. Several agents exist with choice typically guided by the specific clinical scenario. We used a network meta-analysis approach to rate the comparative efficacy and safety of vasopressors for mortality and arrhythmia incidence in septic shock patients.
We performed a comprehensive electronic database search including Medline, Embase, Science Citation Index Expanded and the Cochrane database. Randomised trials investigating vasopressor agents in septic shock patients and specifically assessing 28-day mortality or arrhythmia incidence were included. A Bayesian network meta-analysis was performed using Markov chain Monte Carlo methods.
Thirteen trials of low to moderate risk of bias in which 3146 patients were randomised were included. There was no pairwise evidence to suggest one agent was superior over another for mortality. In the network meta-analysis, vasopressin was significantly superior to dopamine (OR 0.68 (95% CI 0.5 to 0.94)) for mortality. For arrhythmia incidence, standard pairwise meta-analyses confirmed that dopamine led to a higher incidence of arrhythmias than norepinephrine (OR 2.69 (95% CI 2.08 to 3.47)). In the network meta-analysis, there was no evidence of superiority of one agent over another.
In this network meta-analysis, vasopressin was superior to dopamine for 28-day mortality in septic shock. Existing pairwise information supports the use of norepinephrine over dopamine. Our findings suggest that dopamine should be avoided in patients with septic shock and that other vasopressor agents should continue to be based on existing guidelines and clinical judgement of the specific presentation of the patient.
感染性休克是一种危及生命的疾病，需要使用血管活性药物来支持循环系统。有多种药物可供选择，具体选择通常由特定的临床情况决定。我们采用网络荟萃分析方法来评估血管活性药物在感染性休克患者中对死亡率和心律失常发生率的比较疗效及安全性。
我们进行了全面的电子数据库检索，包括Medline、Embase、科学引文索引扩展版和Cochrane数据库。纳入了调查感染性休克患者使用血管活性药物并专门评估28天死亡率或心律失常发生率的随机试验。使用马尔可夫链蒙特卡罗方法进行贝叶斯网络荟萃分析。
纳入了13项偏倚风险低至中度的试验，其中3146例患者被随机分组。没有成对证据表明一种药物在死亡率方面优于另一种药物。在网络荟萃分析中，血管加压素在死亡率方面显著优于多巴胺（OR 0.68（95%CI 0.5至0.94））。对于心律失常发生率，标准的成对荟萃分析证实多巴胺导致的心律失常发生率高于去甲肾上腺素（OR 2.69（95%CI 2.08至3.47））。在网络荟萃分析中，没有证据表明一种药物优于另一种药物。
在这项网络荟萃分析中，血管加压素在感染性休克患者的28天死亡率方面优于多巴胺。现有的成对信息支持在感染性休克患者中使用去甲肾上腺素而非多巴胺。我们的研究结果表明，感染性休克患者应避免使用多巴胺，其他血管活性药物的使用应继续基于现有指南以及对患者具体表现的临床判断。
