血管加压素起始时机与感染性休克患者死亡率的关系：对 MIMIC-III 和 MIMIC-IV 数据库的分析。
Timing of vasopressin initiation and mortality in patients with septic shock: analysis of the MIMIC-III and MIMIC-IV databases.
机构信息
Intensive Care Unit, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou, 310003, Zhejiang Province, P. R. China.
Key Laboratory of Clinical Evaluation Technology for Medical Device of Zhejiang Province, Hangzhou, Zhejiang Province, P.R. China.
出版信息
BMC Infect Dis. 2023 Apr 3;23(1):199. doi: 10.1186/s12879-023-08147-6.
BACKGROUND
vasopressin is commonly used as a second-line vasopressor for patients with septic shock, but the optimal timing of initiation is uncertain. This study was designed to investigate when vasopressin initiation may be beneficial for 28-day mortality in septic shock patients.
METHODS
This was a retrospective observational cohort study from the MIMIC-III v1.4 and MIMIC-IV v2.0 databases. All adults diagnosed with septic shock according to Sepsis-3 criteria were included. Patients were stratified into two groups based on norepinephrine (NE) dose at the time of vasopressin initiation, defined as the low doses of NE group (NE<0.25 µg/kg/min) and the high doses of NE group (NE ≥ 0.25 µg/kg/min). The primary end-point was 28-day mortality after diagnosis of septic shock. The analysis involved propensity score matching (PSM), multivariable logistic regression, doubly robust estimation, the gradient boosted model, and an inverse probability-weighting model.
RESULTS
A total of 1817 eligible patients were included in our original cohort (613 in the low doses of NE group and 1204 in the high doses of NE group). After 1:1 PSM, 535 patients from each group with no difference in disease severity were included in the analysis. The results showed that vasopressin initiation at low doses of NE was associated with reduced 28-day mortality (odds ratio [OR] 0.660, 95% confidence interval [CI] 0.518-0.840, p < 0.001). Compared with patients in the high doses of NE group, patients in the low doses of NE group received significantly shorter duration of NE, with less intravenous fluid volume on the first day after initiation of vasopressin, more urine on the second day, and longer mechanical ventilation-free days and CRRT-free days. Nevertheless, there were no significant differences in hemodynamic response to vasopressin, duration of vasopressin, and ICU or hospital length of stay.
CONCLUSIONS
Among adults with septic shock, vasopressin initiation when low-dose NE was used was associated with an improvement in 28-day mortality.
背景
加压素通常被用作脓毒性休克患者的二线血管加压药，但启动的最佳时机仍不确定。本研究旨在探讨加压素启动时对脓毒性休克患者 28 天死亡率的影响。
方法
这是一项来自 MIMIC-III v1.4 和 MIMIC-IV v2.0 数据库的回顾性观察性队列研究。所有根据 Sepsis-3 标准诊断为脓毒性休克的成年人都被纳入研究。根据加压素启动时去甲肾上腺素（NE）剂量将患者分为两组，定义为低剂量 NE 组（NE<0.25 µg/kg/min）和高剂量 NE 组（NE≥0.25 µg/kg/min）。主要终点为脓毒性休克诊断后 28 天的死亡率。分析包括倾向评分匹配（PSM）、多变量逻辑回归、双重稳健估计、梯度提升模型和逆概率加权模型。
结果
共有 1817 名符合条件的患者纳入原始队列（低剂量 NE 组 613 名，高剂量 NE 组 1204 名）。经过 1:1 PSM 后，每组各有 535 名疾病严重程度无差异的患者纳入分析。结果显示，低剂量 NE 启动加压素与降低 28 天死亡率相关（比值比 [OR] 0.660，95%置信区间 [CI] 0.518-0.840，p<0.001）。与高剂量 NE 组相比，低剂量 NE 组患者接受 NE 的时间明显缩短，加压素启动后第 1 天的静脉输液量更少，第 2 天的尿量更多，机械通气无天数和 CRRT 无天数更长。然而，两组间对加压素的血流动力学反应、加压素持续时间以及 ICU 或住院时间均无显著差异。
结论
在脓毒性休克成人中，使用低剂量 NE 时启动加压素与 28 天死亡率的改善相关。
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