Pediatric Intensive Care Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy.
Neonatal Intensive Care Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy.
Shock. 2024 Nov 1;62(5):599-611. doi: 10.1097/SHK.0000000000002427. Epub 2024 Aug 8.
Background: Hemodynamic support using vasoactive agents is a mainstay in the management of patients with pediatric fluid-refractory septic shock (FRSS). However, evidence supporting the appropriate choice of vasoactive agent is limited. This study aimed to perform a systematic review and meta-analysis on the effect of different first-line vasoactive strategies on mortality in pediatric FRSS. Methods: MEDLINE, Embase, Scopus, CINAHL, Web of Science, the Cochrane Library, ClinicalTrials.gov , and the ISRCTN registry were searched up until December 2023. Randomized controlled trials and observational cohort studies reporting vasoactive agent-specific outcomes of children with FRSS were included. Mortality was assessed as primary outcome in studies on patients receiving dopamine, epinephrine, or norepinephrine as first-line. Random-effects meta-analyses were conducted. Prevalence ratio (PR) estimates were calculated between two drugs when was available in the same study. Findings: Of the 26,284 identified articles, 13 were included, for a total of 997 children. Twelve studies included 748 patients receiving a single vasoactive agent. Of these, 361 received dopamine, 271 epinephrine, and 116 norepinephrine. Overall pooled mortality for patients receiving a single vasoactive was 12% (95% CI 6%-21%) of which 11% (95% CI 3%-36%) for patients receiving dopamine, 17% (95% CI 6%-37%) for epinephrine, and 7% (95% CI 1%-48%) for norepinephrine. Four first-line dopamine (176 patients) and first-line epinephrine (142 patients): dopamine showed a tendency toward higher mortality (PR 1.38, 95% CI 0.81-2.38) and a significant higher need for mechanical ventilation (PR 1.12, 95% CI 1.02-1.22). Interpretation: Among children with FRSS receiving a single vasoactive agent, norepinephrine was associated with the lowest mortality rate. Comparing dopamine and epinephrine, patients receiving epinephrine needed less mechanical ventilation and showed a trend for lower mortality rate. Further research is needed to better delineate the first-line vasoactive agent in this population.
在儿童脓毒性休克伴液体难治性（FRSS）的治疗中，使用血管活性药物进行血流动力学支持是主要方法。然而，支持选择合适的血管活性药物的证据有限。本研究旨在对不同一线血管活性策略对儿科 FRSS 患者死亡率的影响进行系统评价和荟萃分析。
检索 MEDLINE、Embase、Scopus、CINAHL、Web of Science、Cochrane 图书馆、ClinicalTrials.gov 和 ISRCTN 注册中心截至 2023 年 12 月的数据。纳入报告 FRSS 患儿使用特定血管活性药物的结局的随机对照试验和观察性队列研究。研究中接受多巴胺、肾上腺素或去甲肾上腺素作为一线治疗的患者，以死亡率作为主要结局。进行了随机效应荟萃分析。当同一研究中存在两种药物时，计算了两者之间的患病率比（PR）估计值。
在 26284 篇文章中，有 13 篇被纳入，共纳入 997 名儿童。12 项研究纳入了 12 名接受单一血管活性药物治疗的患者。其中，361 名患者接受多巴胺，271 名患者接受肾上腺素，116 名患者接受去甲肾上腺素。接受单一血管活性药物治疗的患者的总体死亡率为 12%（95%CI 6%-21%），其中接受多巴胺的患者死亡率为 11%（95%CI 3%-36%），接受肾上腺素的患者死亡率为 17%（95%CI 6%-37%），接受去甲肾上腺素的患者死亡率为 7%（95%CI 1%-48%）。在 4 项一线多巴胺（176 名患者）和一线肾上腺素（142 名患者）的研究中：多巴胺的死亡率有升高的趋势（PR 1.38，95%CI 0.81-2.38），需要机械通气的比例也显著更高（PR 1.12，95%CI 1.02-1.22）。
在接受单一血管活性药物治疗的 FRSS 患儿中，去甲肾上腺素与最低的死亡率相关。与肾上腺素相比，接受肾上腺素的患者需要更少的机械通气，死亡率也有降低的趋势。需要进一步的研究来更好地确定该人群的一线血管活性药物。
