Mayo Clinic Alix School of Medicine, Mayo Clinic, Rochester, MN.
Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
J Cardiothorac Vasc Anesth. 2024 Jul;38(7):1577-1586. doi: 10.1053/j.jvca.2024.03.014. Epub 2024 Mar 12.
Consensus statements recommend the use of norepinephrine and/or vasopressin for hypotension in cardiac surgery. However, there is a paucity of data among other surgical subgroups and vasopressin analogs. Therefore, the authors conducted a systematic review of randomized controlled trials (RCTs) to compare vasopressin-receptor agonists with norepinephrine for hypotension among those undergoing surgery with general anesthesia. This review was registered prospectively (CRD42022316328). Literature searches were conducted by a medical librarian to November 28, 2023, across MEDLINE, EMBASE, CENTRAL, and Web of Science. The authors included RCTs enrolling adults (≥18 years of age) undergoing any surgery under general anesthesia who developed perioperative hypotension and comparing vasopressin receptor agonists with norepinephrine. The risk of bias was assessed by the Cochrane risk of bias tool for randomized trials (RoB-2). Thirteen (N = 719) RCTs were included, of which 8 (n = 585) enrolled patients undergoing cardiac surgery. Five trials compared norepinephrine with vasopressin, 4 trials with terlipressin, 1 trial with ornipressin, and the other 3 trials used vasopressin as adjuvant therapy. There was no significant difference in all-cause mortality. Among patients with vasoplegic shock after cardiac surgery, vasopressin was associated with significantly lower intensive care unit (N = 385; 2 trials; mean 100.8 v 175.2 hours, p < 0.005; median 120 [IQR 96-168] v 144 [96-216] hours, p = 0.007) and hospital lengths of stay, as well as fewer cases of acute kidney injury and atrial fibrillation compared with norepinephrine. One trial also found that terlipressin was associated with a significantly lower incidence of acute kidney injury versus norepinephrine overall. Vasopressin and norepinephrine restored mean arterial blood pressure with no significant differences; however, the use of vasopressin with norepinephrine was associated with significantly higher mean arterial blood pressure versus norepinephrine alone. Further high-quality trials are needed to determine pooled treatment effects, especially among noncardiac surgical patients and those treated with vasopressin analogs.
共识声明建议在心脏手术中低血压时使用去甲肾上腺素和/或血管加压素。然而，在其他手术亚组和血管加压素类似物中，数据很少。因此，作者进行了一项系统评价，以比较接受全身麻醉手术的患者中血管加压素受体激动剂与去甲肾上腺素治疗低血压的情况。该综述前瞻性注册（CRD42022316328）。文献检索由一名医学图书馆员进行，检索范围截至 2023 年 11 月 28 日，涵盖 MEDLINE、EMBASE、CENTRAL 和 Web of Science。作者纳入了纳入接受全身麻醉下任何手术且围手术期发生低血压的成年患者（≥18 岁）的随机对照试验（RCT），并比较了血管加压素受体激动剂与去甲肾上腺素。使用 Cochrane 偏倚风险工具（RoB-2）评估偏倚风险。纳入了 13 项（N=719）RCT，其中 8 项（n=585）纳入了接受心脏手术的患者。5 项试验比较了去甲肾上腺素与血管加压素，4 项试验比较了特利加压素，1 项试验比较了奥曲肽，另外 3 项试验使用血管加压素作为辅助治疗。全因死亡率无显著差异。在心脏手术后发生血管扩张性休克的患者中，与去甲肾上腺素相比，血管加压素显著降低了 ICU 入住时间（N=385；2 项试验；平均 100.8 小时与 175.2 小时，p<0.005；中位数 120[IQR 96-168]小时与 144[96-216]小时，p=0.007）和住院时间，以及急性肾损伤和心房颤动的发生率也较低。一项试验还发现，特利加压素与去甲肾上腺素相比，总体上急性肾损伤的发生率显著降低。血管加压素和去甲肾上腺素均能使平均动脉血压恢复，但与单独使用去甲肾上腺素相比，联合使用血管加压素和去甲肾上腺素可使平均动脉血压显著升高。需要进一步开展高质量的试验来确定汇总治疗效果，尤其是在非心脏手术患者和接受血管加压素类似物治疗的患者中。
