Goncalves J A, Hydo L J, Barie P S
Department of Surgery, The New York Presbyterian Hospital-Cornell Medical Center, New York 10021, USA.
Shock. 1998 Oct;10(4):231-6. doi: 10.1097/00024382-199810000-00001.
Several studies indicate that norepinephrine (NE) may be more effective than dopamine for the treatment of septic shock. Nonetheless, many consider dopamine to be the pressor of choice for shock refractory to volume resuscitation. Owing to fear of excessive vasoconstriction, accentuated end-organ hypoperfusion, and the development of multiple organ dysfunction syndrome (MODS), it is contended that NE may be deleterious. We analyzed the duration of NE use and the variables that predict mortality in a consecutive cohort of 406 surgical intensive care unit patients treated with NE for shock. Study parameters included age, acute physiology and chronic health evaluation (APACHE) II and APACHE III scores, hospital (HLOS) and intensive care unit (ULOS) length of stay, maximal and daily multiple organ dysfunction (MOD) scores, MOD score minus cardiovascular points (MOD-CV), duration of NE infusion, and survival. The duration of NE infusion was stratified into six subsets (1, 2, 3-5, 6-10, 11-20, and > or =21 days). An age- and APACHE II and III score-matched cohort of 195 patients, in whom NE was not utilized, was identified retrospectively for comparison. The prevalence of NE use was 10.9%. NE patients developed MODS to a greater degree (11.7 +/- .3 vs. 5.9 +/- .4 points, p < .0001). NE patients had a greater degree (p < .0001) of noncardiovascular MOD as well. When stratified by survival, a greater degree of MOD occurred in both nonsurvivors and survivors of NE (both, p < .0001) compared with comparably ill patients without pressor-dependent shock. MOD scores, ULOS, and HLOS increased progressively with prolonged NE therapy (all, p < .0005), whereas mortality increased significantly only when the duration of NE infusion exceeded 10 days (p = .05). By multivariate analysis of variance (ANOVA), MOD score (p < .0001), and APACHE III (p < .01) predicted mortality, but notably the duration of NE therapy failed to attain predictive value (p = .3192). Only the MOD score was predictive of HLOS (p = .0001) and ULOS (p = .003). Daily MOD scores revealed that nonsurvivors of NE therapy were admitted to the intensive care unit with a greater degree of baseline organ dysfunction than NE survivors (7.5 +/- .4 vs. 5.1 +/- .2 for survivors, p < .0001). In addition, whereas survivors showed significant improvement by Day 5 (p < .01), MOD amongst nonsurvivors remained unchanged (p = .993). Although critically ill surgical patients requiring NE support have significantly greater degrees of organ dysfunction than patients not requiring pressors, much of the organ dysfunction is present on admission. The data contradict the notion that NE facilitates the development of MODS.
多项研究表明，去甲肾上腺素（NE）在治疗感染性休克方面可能比多巴胺更有效。尽管如此，许多人仍认为多巴胺是对容量复苏无反应的休克的首选升压药。由于担心过度血管收缩、加重终末器官灌注不足以及多器官功能障碍综合征（MODS）的发生，有人认为NE可能有害。我们分析了406例接受NE治疗休克的外科重症监护病房连续患者队列中NE的使用时间以及预测死亡率的变量。研究参数包括年龄、急性生理学与慢性健康状况评估（APACHE）II和APACHE III评分、住院（HLOS）和重症监护病房（ULOS）住院时间、最大和每日多器官功能障碍（MOD）评分、MOD评分减去心血管评分（MOD-CV）、NE输注时间以及生存率。NE输注时间分为六个亚组（1天、2天、3 - 5天、6 - 10天、11 - 20天以及≥21天）。回顾性确定了195例未使用NE且年龄、APACHE II和III评分匹配的队列用于比较。NE的使用率为10.9%。使用NE的患者发生MODS的程度更高（11.7±0.3分对5.9±0.4分，p<0.0001）。使用NE的患者非心血管性MOD的程度也更高（p<0.0001）。按生存情况分层时，与无升压药依赖休克的病情相当的患者相比，使用NE的非幸存者和幸存者发生MOD的程度均更高（两者均p<0.0001）。随着NE治疗时间延长，MOD评分、ULOS和HLOS逐渐增加（均p<0.0005），而仅当NE输注时间超过10天时死亡率显著增加（p = 0.05）。通过多变量方差分析（ANOVA），MOD评分（p<0.0001）和APACHE III（p<0.01）可预测死亡率，但值得注意的是NE治疗时间未达到预测价值（p = 0.3192）。只有MOD评分可预测HLOS（p = 0.0001）和ULOS（p = 0.003）。每日MOD评分显示，NE治疗的非幸存者入住重症监护病房时的基线器官功能障碍程度比NE幸存者更高（幸存者为5.1±0.2分，非幸存者为7.5±0.4分，p<0.0001）。此外，虽然幸存者在第5天时显示出显著改善（p<0.01），但非幸存者的MOD保持不变（p = 0.993）。尽管需要NE支持的重症外科患者的器官功能障碍程度比不需要升压药的患者显著更高，但许多器官功能障碍在入院时就已存在。这些数据与NE促进MODS发生的观点相矛盾。
