脓毒性休克中血管加压素起始时机与院内死亡率：大型公共数据库的观察性研究

Vasopressin Initiation Timing and In-Hospital Mortality in Septic Shock: An Observational Study of Large Public Databases.

作者信息

Sacha Gretchen L, Duggal Abhijit, Reddy Anita J, Wang Lu, Bauer Seth R

机构信息

Department of Pharmacy, Cleveland Clinic, Cleveland, OH.

Critical Care Center, Cleveland Clinic, Cleveland, OH.

出版信息

Crit Care Explor. 2025 Aug 22;7(9):e1284. doi: 10.1097/CCE.0000000000001284. eCollection 2025 Sep 1.

DOI:10.1097/CCE.0000000000001284

PMID:40844800

原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC12377302/

Abstract

IMPORTANCE

Vasopressin is used in one-third of patients with septic shock to augment hemodynamics and reduce overall catecholamine exposure. However, the optimal clinical context in which to initiate vasopressin is unknown.

OBJECTIVES

To determine the association between norepinephrine-equivalent dose, lactate concentration, and time duration from shock onset at vasopressin initiation with in-hospital mortality.

DESIGN, SETTING, AND PARTICIPANTS: Retrospective, observational evaluation utilizing Medical Information Mart for Intensive Care-IV and electronic ICU Collaborative Research Database databases of adult patients with septic shock based on modified Sepsis-3 criteria receiving continuous infusion catecholamines.

MAIN OUTCOMES AND MEASURES

The associations of norepinephrine-equivalent dose, lactate concentration, and time duration from shock onset at vasopressin initiation with in-hospital mortality were evaluated with multivariable regression models.

RESULTS

In total, 1409 patients from 209 hospitals were included. At vasopressin initiation patients had a median (interquartile range) norepinephrine-equivalent dose 28.4 µg/min (16.4-42.6 µg/min), lactate concentration 3.7 mmol/L (2.5-6.2 mmol/L), and 5.6 hours (2.0-13.5 hr) had elapsed since shock onset. All three variables of interest were associated with in-hospital mortality. Three restricted cubic spline knots were identified where the relationship between norepinephrine-equivalent dose and in-hospital mortality changed substantially: 9, 28, and 72 µg/min. The odds of in-hospital mortality increased by 90% and 3.9-fold when comparing vasopressin initiation at norepinephrine-equivalent doses of 28 µg/min and 72 µg/min to 9 µg/min, respectively (adjusted odds ratio [OR], 1.90 [95% CI, 1.49-2.41] and 3.93 [95% CI, 2.74-5.64]). The odds of in-hospital mortality increased by 16% for every mmol/L in the lactate concentration at vasopressin initiation (adjusted OR, 1.16 [95% CI, 1.11-1.21]). Finally, the odds of in-hospital mortality increased by 3% for every hour in the time duration from shock onset to vasopressin initiation (adjusted OR, 1.03 [95% CI, 1.01-1.04]).

CONCLUSIONS AND RELEVANCE

Earlier adjunctive vasopressin initiation may decrease mortality in patients with septic shock.

摘要

重要性

三分之一的感染性休克患者使用血管加压素以增强血流动力学并减少儿茶酚胺的总体暴露。然而，启动血管加压素的最佳临床背景尚不清楚。

目的

确定去甲肾上腺素等效剂量、乳酸浓度以及从休克发作到启动血管加压素的持续时间与住院死亡率之间的关联。

设计、设置和参与者：利用重症监护医学信息集市-IV和电子ICU协作研究数据库对符合改良脓毒症-3标准且接受持续输注儿茶酚胺的成年感染性休克患者进行回顾性观察评估。

主要结局和衡量指标

采用多变量回归模型评估去甲肾上腺素等效剂量、乳酸浓度以及从休克发作到启动血管加压素的持续时间与住院死亡率之间的关联。

结果

总共纳入了来自209家医院的1409例患者。在启动血管加压素时，患者的去甲肾上腺素等效剂量中位数（四分位间距）为28.4μg/分钟（16.4 - 42.6μg/分钟），乳酸浓度为3.7mmol/L（2.5 - 6.2mmol/L），自休克发作起已过去5.6小时（2.0 - 13.5小时）。所有三个感兴趣的变量均与住院死亡率相关。确定了三个受限立方样条节点，在这些节点上去甲肾上腺素等效剂量与住院死亡率之间的关系发生了显著变化：9、28和72μg/分钟。与在去甲肾上腺素等效剂量为9μg/分钟时启动血管加压素相比，在去甲肾上腺素等效剂量为28μg/分钟和72μg/分钟时启动血管加压素，住院死亡率的比值分别增加了90%和3.9倍（调整后的比值比[OR]，1.90[95%置信区间，1.49 - 2.41]和3.93[95%置信区间，2.74 - 5.64]）。在启动血管加压素时，乳酸浓度每增加1mmol/L，住院死亡率的比值增加16%（调整后的OR，1.16[95%置信区间，1.11 - 1.21]）。最后，从休克发作到启动血管加压素的持续时间每增加1小时，住院死亡率的比值增加3%（调整后的OR，1.03[95%置信区间，1.01 - 1.04]）。