Andrei Stefan, Nguyen Maxime, Abou-Arab Osama, Bouhemad Belaid, Guinot Pierre-Grégoire
Anaesthesiology and Critical Care Department, Dijon Bourgogne University Hospital, Dijon, France.
Anaesthesiology and Intensive Care Department, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.
Front Med (Lausanne). 2022 Feb 22;9:818386. doi: 10.3389/fmed.2022.818386. eCollection 2022.
The optimal management of hypotensive patients during norepinephrine weaning is unclear. The primary study aim was to assess the ability of preload dependence to predict hypotension following norepinephrine weaning. The secondary aims were to describe the effect of norepinephrine weaning on preload dependence, and the cardiovascular effects of fluid expansion in hypotensive patients following norepinephrine weaning.
This was a prospective observational monocentric study. We included PiCCO®-monitored patients with norepinephrine-treated septic shock, for whom the physician decided to decrease the norepinephrine dosage during the de-escalation phase. Three consecutive steps were evaluated with hemodynamic measurements: baseline, after norepinephrine decrease, and after 500 mL fluid expansion.
Forty-five patients were included. Preload dependence assessed by stroke volume changes following passive leg raising was not predictive of pressure response to norepinephrine weaning [AUC of 0.42 (95%CI: 0.25-0.59, = 0.395)]. After fluid expansion, there was no difference in the prior preload dependence between pressure-responders and non-pressure-responders (14 vs. 13%, = 1). The pressure response to norepinephrine decrease was not associated with pressure response after fluid expansion (40 vs. 23%, = 0.211).
Hypotension following norepinephrine decrease was not predicted by preload dependence, and there was no association between arterial hypotension after norepinephrine decrease and fluid response.
去甲肾上腺素撤药期间低血压患者的最佳管理尚不清楚。主要研究目的是评估前负荷依赖性预测去甲肾上腺素撤药后低血压的能力。次要目的是描述去甲肾上腺素撤药对前负荷依赖性的影响，以及去甲肾上腺素撤药后低血压患者液体扩容的心血管效应。
这是一项前瞻性观察性单中心研究。我们纳入了使用脉波指示剂连续心排血量监测仪（PiCCO®）监测的去甲肾上腺素治疗的感染性休克患者，医生决定在降级阶段降低去甲肾上腺素剂量。通过血流动力学测量评估三个连续步骤：基线、去甲肾上腺素降低后以及500 mL液体扩容后。
纳入45例患者。通过被动抬腿后每搏量变化评估的前负荷依赖性不能预测对去甲肾上腺素撤药的压力反应【曲线下面积为0.42（95%置信区间：0.25 - 0.59，P = 0.395）】。液体扩容后，压力反应者和无压力反应者之间先前的前负荷依赖性无差异（14%对13%，P = 1）。对去甲肾上腺素降低的压力反应与液体扩容后的压力反应无关（40%对23%，P = 0.211）。
前负荷依赖性不能预测去甲肾上腺素降低后的低血压，去甲肾上腺素降低后的动脉低血压与液体反应之间无关联。
