Rudis M I, Basha M A, Zarowitz B J
Department of Pharmacy Services, Henry Ford Hospital, Detroit, MI 48202, USA.
Crit Care Med. 1996 Mar;24(3):525-37. doi: 10.1097/00003246-199603000-00026.
To review the literature on the current use of vasopressors and inotropes in patients with sepsis and sepsis syndrome with respect to the choice of agent, therapeutic end points, and safe and effective doses to be used. To examine the available evidence that supports or refutes goal-directed therapy toward supranormal oxygen transport in optimizing the outcome of critically ill sepsis syndrome patients.
All pertinent English and French articles dealing with hemodynamic support with selected vasopressors and inotropic agents in human sepsis and sepsis syndrome retrieved from a computerized MEDLINE search from 1985 to 1994.
Clinical studies with norepinephrine, epinephrine, phenylephrine, dopamine, and dobutamine in sepsis syndrome were considered if goal-directed therapy with oxygen transport variables was utilized. Emphasis was placed on prospective, randomized, controlled comparative trials. However, open-label, observational, and comparative studies, or case series, were also evaluated when limited data were available.
From the selected studies, information was obtained regarding patient population, dosing regimen, type of therapeutic goals or end points (hemodynamic, or normal vs. supranormal oxygen transport variables) and outcome data (e.g., achievement of goals, resolution of the episode, mortality rate, and development of end-organ dysfunction).
When used in larger than usual doses, epinephrine, norepinephrine, and phenylephrine uniformly increased hemodynamic values. Epinephrine may increase oxygen transport values more reliably than norepinephrine. Dobutamine doses in the range of 2.5 to 6 microgram/kg/min increase oxygen transport variables and hemodynamics to predetermined goals in only 30% to 70% of patients. Larger infusion rates offer no further benefits.
Insufficient evidence exists to support goal-directed therapy with vasopressors and inotropes in the treatment of sepsis syndrome. No definitive recommendations can be made about the superiority of a vasopressor or inotropic agent due to the lack of data. However, it may be that evaluation of vasopressors earlier in sepsis syndrome will yield more promising results. Large, comparative, controlled trials assessing mortality rate and development of multiple organ system dysfunction are needed.
回顾关于脓毒症和脓毒症综合征患者目前使用血管升压药和正性肌力药的文献，内容涉及药物选择、治疗终点以及所用的安全有效剂量。审查现有证据，这些证据支持或反驳在优化重症脓毒症综合征患者预后方面针对超常氧输送的目标导向治疗。
通过计算机检索MEDLINE数据库，获取1985年至1994年间所有有关在人类脓毒症和脓毒症综合征中使用选定血管升压药和正性肌力药进行血流动力学支持的相关英文和法文文章。
如果采用了针对氧输送变量的目标导向治疗，则纳入有关去甲肾上腺素、肾上腺素、去氧肾上腺素、多巴胺和多巴酚丁胺用于脓毒症综合征的临床研究。重点是前瞻性、随机、对照比较试验。然而，当数据有限时，也对开放标签、观察性和比较性研究或病例系列进行了评估。
从选定的研究中，获取了有关患者人群、给药方案、治疗目标或终点类型（血流动力学，或正常与超常氧输送变量）以及结局数据（如目标达成情况、病情缓解情况、死亡率和终末器官功能障碍的发生）的信息。
当以高于常规剂量使用时，肾上腺素、去甲肾上腺素和去氧肾上腺素均能一致地提高血流动力学值。肾上腺素可能比去甲肾上腺素更可靠地提高氧输送值。剂量在2.5至6微克/千克/分钟范围内的多巴酚丁胺仅能使30%至70%的患者的氧输送变量和血流动力学达到预定目标。更高的输注速率并无更多益处。
现有证据不足，无法支持在脓毒症综合征治疗中使用血管升压药和正性肌力药进行目标导向治疗。由于缺乏数据，无法就血管升压药或正性肌力药的优越性给出明确建议。然而，在脓毒症综合征早期对血管升压药进行评估可能会产生更有前景的结果。需要开展评估死亡率和多器官系统功能障碍发生情况的大型、比较性、对照试验。
