Department of Medicine, Detroit Medical Center/Wayne State University, Detroit, MI, USA.
Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC) Laboratory, Mayo Clinic, Rochester, MN, USA.
J Intensive Care Med. 2020 Jun;35(6):554-561. doi: 10.1177/0885066618768180. Epub 2018 Apr 8.
Weight-based dosing strategy for norepinephrine in septic shock patients with extremes of body mass index has been lesser studied.
This historical study of adult septic shock patients was conducted from January 1, 2010, to December 31, 2015, at all intensive care units (ICUs) in Mayo Clinic, Rochester. Patients with documented body mass index were classified into underweight (body mass index <18.5 kg/m), normal weight (18.5-24.9 kg/m), and morbidly obese (≥40 kg/m) patients. Patients with repeat ICU admissions, ICU stay <1 day, and body mass index 25 to 39.9 kg/m were excluded. The primary outcome was in-hospital mortality, and secondary outcomes included cumulative norepinephrine exposure acute kidney injury, cardiac arrhythmias, and 1-year mortality. Two-tailed < .05 was considered statistically significant.
From 2010 to 2015, 2016 patients met inclusion-145, 1406, and 466 patients, respectively, in underweight, normal weight, and morbidly obese cohorts. Underweight patients used the highest peak dose and absolute exposure was greatest for morbidly obese patients. In-hospital mortality decreased with increasing log body mass index: 41.4% (underweight), 28.4% (normal weight), and 24.7% (morbidly obese), respectively ( < .001); however, this relationship was not noted at 1 year. Unadjusted log norepinephrine cumulative exposure (mg) was associated with higher in-hospital mortality, acute kidney injury, cardiac arrhythmias, and 1-year mortality. After adjustment for demographics, body mass index, comorbidity, and illness severity, log norepinephrine exposure was an independent predictor of in-hospital mortality (odds ratio 2.4 [95% confidence interval, 2.0-2.8]; < .001) and 1-year mortality (odds ratio 1.7 [95% confidence interval, 1.5-2.0]; < .001). In a propensity-matched analysis of 1140 patients, log norepinephrine was an independent predictor of in-hospital mortality (odds ratio 2.2 [95% confidence interval, 1.8-2.6]; < .001).
Morbidly obese patients had lower in-hospital mortality but had higher 1-year mortality compared to normal weight and underweight patients. Cumulative norepinephrine exposure was highest in morbidly obese patients. Total norepinephrine exposure was an independent mortality predictor in septic shock.
对于体质量指数（BMI）极端的脓毒性休克患者，去甲肾上腺素的基于体重的给药策略研究较少。
这项对成年脓毒性休克患者的历史性研究于 2010 年 1 月 1 日至 2015 年 12 月 31 日在梅奥诊所的所有重症监护病房（ICU）进行。有记录 BMI 的患者分为体重不足（BMI＜18.5kg/m）、正常体重（18.5-24.9kg/m）和病态肥胖（≥40kg/m）患者。排除重复 ICU 入院、ICU 入住时间＜1 天和 BMI 为 25 至 39.9kg/m 的患者。主要结局是院内死亡率，次要结局包括累积去甲肾上腺素暴露、急性肾损伤、心律失常和 1 年死亡率。双侧 P＜0.05 被认为具有统计学意义。
2010 年至 2015 年，共有 2016 名患者符合纳入标准，分别归入体重不足、正常体重和病态肥胖队列的 145、1406 和 466 名患者。体重不足的患者使用了最高的峰剂量，病态肥胖的患者绝对暴露量最大。随着 logBMI 的增加，院内死亡率降低：分别为 41.4%（体重不足）、28.4%（正常体重）和 24.7%（病态肥胖）（P＜0.001）；然而，在 1 年时并未观察到这种关系。未调整的去甲肾上腺素累积暴露（mg）与较高的院内死亡率、急性肾损伤、心律失常和 1 年死亡率相关。在校正人口统计学、BMI、合并症和疾病严重程度后，log 去甲肾上腺素暴露是院内死亡率（优势比 2.4[95%置信区间，2.0-2.8]；P＜0.001）和 1 年死亡率（优势比 1.7[95%置信区间，1.5-2.0]；P＜0.001）的独立预测因子。在对 1140 名患者进行的倾向匹配分析中，log 去甲肾上腺素是院内死亡率的独立预测因子（优势比 2.2[95%置信区间，1.8-2.6]；P＜0.001）。
病态肥胖患者的院内死亡率较低，但与正常体重和体重不足的患者相比，1 年死亡率较高。去甲肾上腺素的累积暴露量在病态肥胖患者中最高。脓毒性休克患者的总去甲肾上腺素暴露是死亡率的独立预测因子。
