血管加压素反应与脓毒性休克患者的临床病程。
Vasopressin Response and Clinical Trajectory in Septic Shock Patients.
机构信息
Department of Pharmacy, 2569Cleveland Clinic, Cleveland, OH, USA.
Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, USA.
出版信息
J Intensive Care Med. 2023 Mar;38(3):273-279. doi: 10.1177/08850666221118282. Epub 2022 Sep 4.
BACKGROUND
In septic shock, vasopressors aim to improve tissue perfusion and prevent persistent organ dysfunction, a characteristic of chronic critical illness (CCI). Adjunctive vasopressin is often used to decrease catecholamine dosage, but the association of vasopressin response with subsequent patient outcomes is unclear. We hypothesized vasopressin response is associated with favorable clinical trajectory.
METHODS
We included patients with septic shock receiving vasopressin as a catecholamine adjunct in this retrospective cohort study. We defined vasopressin response as a lowering of the catecholamine dose required to maintain mean arterial pressure ≥65 mm Hg, 6 h after vasopressin initiation. Clinical trajectories were adjudicated as early death (ED; death before day 14), CCI (ICU stay ≥14 days with persistent organ dysfunction), or rapid recovery (RR; not meeting ED or CCI criteria). Trajectories were placed on an ordinal scale with ED the worst outcome, CCI next, and RR the best outcome. The association of vasopressin response with clinical trajectory was assessed with multivariable ordinal logistic regression.
RESULTS
In total 938 patients were included; 426 (45.4%) were vasopressin responders. The most frequent trajectory was ED (49.8%), 29.7% developed CCI, and 20.5% had rapid recovery. In survivors to ICU day 14 (those without ED), 59.2% had CCI and 40.8% experienced RR. Compared with vasopressin non-responders, vasopressin responders less frequently experienced ED (42.5% vs. 55.9%) and more frequently experienced RR (24.6% vs. 17.0%; < 0.01). After controlling for confounders, vasopressin response was independently associated with higher odds of developing a better clinical trajectory (OR 1.63; 95% CI 1.26-2.10). Medical patients most frequently developed ED and survivors more commonly developed CCI than RR; surgical patients developed the three trajectories with similar frequency ( < 0.01).
CONCLUSIONS
Vasopressin responsive status was associated with improved clinical trajectory in septic shock patients. Early vasopressin response is a potential novel prognostic marker for short-term clinical trajectory.
背景
在感染性休克中，血管加压素的目的是改善组织灌注并预防持续的器官功能障碍，这是慢性危重病（CCI）的特征。辅助性血管加压素常被用于减少儿茶酚胺的剂量，但血管加压素反应与随后的患者预后的关系尚不清楚。我们假设血管加压素反应与良好的临床轨迹相关。
方法
我们纳入了在这项回顾性队列研究中接受血管加压素作为儿茶酚胺辅助治疗的感染性休克患者。我们将血管加压素反应定义为血管加压素开始后 6 小时内降低维持平均动脉压≥65mmHg所需的儿茶酚胺剂量。临床轨迹通过早期死亡（ED；14 天内死亡）、CCI（ICU 住院时间≥14 天，持续存在器官功能障碍）或快速恢复（RR；不符合 ED 或 CCI 标准）进行判断。轨迹被放在一个有序尺度上，ED 是最差的结果，CCI 次之，RR 是最好的结果。使用多变量有序逻辑回归评估血管加压素反应与临床轨迹的关系。
结果
共纳入 938 例患者；426 例（45.4%）为血管加压素反应者。最常见的轨迹是 ED（49.8%），29.7%发展为 CCI，20.5%快速恢复。在 ICU 第 14 天存活的患者（无 ED 者）中，59.2%发生 CCI，40.8%经历 RR。与血管加压素无反应者相比，血管加压素反应者较少发生 ED（42.5% vs. 55.9%），更多发生 RR（24.6% vs. 17.0%； < 0.01）。在控制了混杂因素后，血管加压素反应与更好的临床轨迹的更高可能性独立相关（OR 1.63；95% CI 1.26-2.10）。内科患者最常发生 ED，幸存者更常见的是 CCI 而不是 RR；外科患者发生这三种轨迹的频率相似（ < 0.01）。
结论
血管加压素反应状态与感染性休克患者的临床轨迹改善相关。早期的血管加压素反应可能是短期临床轨迹的一个新的潜在预后标志物。
Zotero 插件