小剂量去甲肾上腺素对小儿休克期间脑氧合及灌注的影响
Low Dosing Norepinephrine Effects on Cerebral Oxygenation and Perfusion During Pediatric Shock.
作者信息
Vedrenne-Cloquet Meryl, Chareyre Judith, Léger Pierre-Louis, Genuini Mathieu, Renolleau Sylvain, Oualha Mehdi
机构信息
Pediatric Intensive Care Unit, AP-HP CHU Necker-Enfants Malades, Paris, France.
Pediatric Intensive Care Unit, AP-HP CHU Trousseau-La Roche Guyon, Paris, France.
出版信息
Front Pediatr. 2022 Jul 6;10:898444. doi: 10.3389/fped.2022.898444. eCollection 2022.
BACKGROUND
Cerebral hypoperfusion and impaired oxygen delivery during pediatric critical illness may result in acute neurologic injury with subsequent long-term effects on neurodevelopmental outcome. Yet, the impact of norepinephrine on cerebral hemodynamics is unknown in children with shock. We aimed to describe the norepinephrine effects on cerebral perfusion and oxygenation during pediatric shock.
PATIENTS AND METHODS
We conducted an observational multicentre prospective study in 3 French pediatric intensive care units. Children <18 years of age excluding traumatic brain injury were included in the study if they need norepinephrine for shock. Systemic and cerebral hemodynamics were compared between the time of initiation of norepinephrine (T), and the steady-state (T). Cardiac output (CO) was measured using ultrasound. Cerebral perfusion was assessed on middle cerebral arteries (MCA) using transcranial doppler ultrasound. Cerebral tissue oxygen saturation (rScO) was recorded using near infrared spectroscopy, and we calculated cerebral fractional tissue oxygen extraction (cFTOE = SpO-rScO/SpO).
MAIN RESULTS
Fourteen children (median [IQR] age of 3.5[1; 13.5] years) were included. Norepinephrine at 0.2[0.1; 0.32] μg/kg/min significantly increased mean arterial blood pressure (61[56; 73] mmHg at T vs. 49[42;54] mmHg at T, p=10) without change of CO. MCA velocities, pulsatility index, rScO, and cFTOE did not significantly change between T and T. Some individuals observed variations in estimated CBF, which slightly improved in 7 patients, remained unchanged in 5, and was impaired in 2. No patient experienced significant variations of rScO.
CONCLUSIONS
Low-dosing norepinephrine, despite a homogeneous and significant increase in arterial blood pressure, had little effects on cerebral perfusion and oxygenation during pediatric shock. This reinforces the need for personalized tailored therapies in this population.
TRIAL REGISTRATION
Clinicaltrials.gov, NCT03731104. Registered 6 November, 2018. https://clinicaltrials.gov/ct2/show/NCT03731104.
背景
小儿危重症期间的脑灌注不足和氧输送受损可能导致急性神经损伤，进而对神经发育结局产生长期影响。然而，去甲肾上腺素对休克患儿脑血流动力学的影响尚不清楚。我们旨在描述去甲肾上腺素对小儿休克期间脑灌注和氧合的影响。
患者与方法
我们在法国3个儿科重症监护病房进行了一项观察性多中心前瞻性研究。年龄小于18岁且排除创伤性脑损伤的儿童，若因休克需要使用去甲肾上腺素，则纳入本研究。比较去甲肾上腺素起始使用时（T0）和稳态时（T1）的全身和脑血流动力学。使用超声测量心输出量（CO）。使用经颅多普勒超声评估大脑中动脉（MCA）的脑灌注。使用近红外光谱记录脑组织氧饱和度（rScO2），并计算脑部分组织氧摄取率（cFTOE = SpO2 - rScO2 / SpO2）。
主要结果
纳入了14名儿童（年龄中位数[四分位间距]为3.5[1；13.5]岁）。去甲肾上腺素剂量为0.2[0.1；0.32]μg/kg/min时，平均动脉血压显著升高（T0时为61[56；73]mmHg，T1时为49[42；54]mmHg，p = 0.01），而CO无变化。T0和T1之间，MCA血流速度、搏动指数、rScO2和cFTOE均无显著变化。部分个体的估计脑血流量（CBF）出现变化，7例患者略有改善，5例无变化，2例受损。无患者rScO2出现显著变化。
结论
低剂量去甲肾上腺素尽管能使动脉血压均匀且显著升高，但对小儿休克期间的脑灌注和氧合影响不大。这进一步凸显了对该人群进行个性化定制治疗的必要性。
试验注册
Clinicaltrials.gov，NCT03731104。于2018年11月6日注册。https://clinicaltrials.gov/ct2/show/NCT03731104 。
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