Department of Intensive Care Medicine, University of Bern, Bern University Hospital, Bern, Switzerland.
Semin Respir Crit Care Med. 2021 Oct;42(5):683-688. doi: 10.1055/s-0041-1733897. Epub 2021 Sep 20.
Sepsis can influence blood volume, its distribution, vascular tone, and cardiac function. Persistent hypotension or the need for vasopressors after volume resuscitation is part of the definition of septic shock. Since increased positive fluid balance has been associated with increased morbidity and mortality in sepsis, timing of vasopressors in the treatment of septic shock seems crucial. However, conclusive evidence on timing and sequence of interventions with the goal to restore tissue perfusion is lacking. The aim of this narrative review is to depict the pathophysiology of hypotension in sepsis, evaluate how common interventions to treat hypotension interfere with physiology, and to give a resume of the results from clinical studies focusing on targets and timing of vasopressor in sepsis. The majority of studies comparing early versus late administration of vasopressors in septic shock are rather small, single-center, and retrospective. The range of "early" is between 1 and 12 hours. The available studies suggest a mean arterial pressure of 60 to 65 mm Hg as a threshold for increased risk of morbidity and mortality, whereas higher blood pressure targets do not seem to add further benefits. The data, albeit mostly from observational studies, speak for combining vasopressors with fluids rather "early" in the treatment of septic shock (within a 0-3-hour window). Nevertheless, the optimal resuscitation strategy should take into account the source of infection, the pathophysiology, the time and clinical course preceding the diagnosis of sepsis, and also comorbidities and sepsis-induced organ dysfunction.
败血症会影响血容量、分布、血管张力和心功能。容量复苏后持续性低血压或需要升压药是败血症性休克的定义的一部分。由于正性液体平衡增加与败血症的发病率和死亡率增加有关，因此在败血症休克的治疗中升压药的时机似乎至关重要。然而，缺乏关于以恢复组织灌注为目标的干预措施的时机和顺序的明确证据。本叙述性综述的目的是描述败血症性低血压的病理生理学，评估治疗低血压的常见干预措施如何干扰生理学，并总结关注败血症升压药目标和时机的临床研究结果。比较败血症性休克中早期与晚期使用升压药的大多数研究规模较小、单中心、回顾性。“早期”的范围在 1 到 12 小时之间。现有研究表明，平均动脉压为 60 至 65mmHg 作为发病率和死亡率增加风险的阈值，而较高的血压目标似乎不会带来额外的益处。尽管这些数据主要来自观察性研究，但支持在败血症休克治疗中（在 0-3 小时的窗口期内）将升压药与液体联合使用，即“早期”。然而，最佳复苏策略应考虑感染源、病理生理学、败血症诊断前的时间和临床过程，以及合并症和败血症引起的器官功能障碍。
