Department of Internal Medicine, University of California, Sacramento, CA, USA.
Department of Emergency Medicine, University of California, Sacramento, CA, USA.
Expert Rev Clin Pharmacol. 2022 Aug;15(8):959-976. doi: 10.1080/17512433.2022.2110067. Epub 2022 Aug 9.
Septic and vasoplegic shock are common types of vasodilatory shock (VS) with high mortality. After fluid resuscitation and the use of catecholamine-mediated vasopressors (CMV), vasopressin, angiotensin II, methylene blue (MB), and hydroxocobalamin can be added to maintain blood pressure.
VS treatment utilizes a phased approach with secondary vasopressors added to vasopressor agents to maintain an acceptable mean arterial pressure (MAP). This review covers additional vasopressors and adjunctive therapies used when fluid and catecholamine-mediated vasopressors fail to maintain target MAP.
Evidence supporting additional vasopressor agents in catecholamine-resistant VS is limited to case reports, series, and a few randomized control trials (RCTs) to guide recommendations. Vasopressin is the most common agent added next when MAPs are not adequately supported with CMV. VS patients failing fluids and vasopressors with cardiomyopathy may have cardiotonic agents such as dobutamine or milrinone added before or after vasopressin. Angiotensin II, another class of vasopressor, is used in VS to maintain adequate MAP. MB and/or hydroxocobalamin, vitamin C, thiamine, and corticosteroids are adjunctive therapies used in refractory VS. More RCTs are needed to confirm the utility of these drugs, at what doses, which combinations and in what order they should be given.
感染性休克和血管扩张性休克（VS）是常见的血管舒张性休克类型，死亡率较高。在液体复苏和使用儿茶酚胺介导的血管加压剂（CMV）后，可以添加血管加压素、血管紧张素 II、亚甲蓝（MB）和羟钴胺素来维持血压。
VS 的治疗采用分阶段方法，将次级血管加压剂添加到血管加压剂中以维持可接受的平均动脉压（MAP）。本综述涵盖了在液体和儿茶酚胺介导的血管加压剂无法维持目标 MAP 时使用的其他血管加压剂和辅助治疗。
支持在儿茶酚胺抵抗性 VS 中使用其他血管加压剂的证据仅限于病例报告、系列和少数随机对照试验（RCT），以指导建议。当 CMV 不能充分支持 MAP 时，最常添加的血管加压剂是血管加压素。患有心肌病的 VS 患者在液体和血管加压剂治疗失败后，可能会在使用血管加压素之前或之后添加正性肌力药物，如多巴酚丁胺或米力农。血管紧张素 II 是另一种血管加压剂，用于维持足够的 MAP。MB 和/或羟钴胺素、维生素 C、硫胺素和皮质类固醇是难治性 VS 的辅助治疗。需要更多的 RCT 来确认这些药物的效用、剂量、组合以及它们应该以何种顺序给药。
