Argenziano M, Chen J M, Choudhri A F, Cullinane S, Garfein E, Weinberg A D, Smith C R, Rose E A, Landry D W, Oz M C
Departments of Surgery and Medicine, Columbia University College of Physicians and Surgeons, New York, USA.
J Thorac Cardiovasc Surg. 1998 Dec;116(6):973-80. doi: 10.1016/S0022-5223(98)70049-2.
Cardiopulmonary bypass can be associated with vasodilatory hypotension requiring pressor support. We have previously found arginine vasopressin to be a remarkably effective pressor in a variety of vasodilatory shock states. We investigated the incidence and clinical predictors of vasodilatory shock in a general population of cardiac surgical patients and the effects of low-dose arginine vasopressin as treatment of this syndrome in patients with heart failure.
Patients undergoing cardiopulmonary bypass (n = 145) were studied prospectively. Preoperative ejection fraction, medications, and perioperative hemodynamics were recorded, and postbypass serum arginine vasopressin levels were measured. Vasodilatory shock was defined as a mean arterial pressure lower than 70 mm Hg, a cardiac index greater than 2.5 L/min/m2, and norepinephrine dependence. Predictors of vasodilatory shock were investigated by logistic regression analysis. The hemodynamic responses of patients who received arginine vasopressin infusions for vasodilatory shock after cardiopulmonary bypass for left ventricular assist device placement or heart transplantation were analyzed retrospectively.
Eleven of 145 general cardiac surgery patients (8%) met criteria for postbypass vasodilatory shock. By multivariate analysis, an ejection fraction lower than 0.35 and angiotensin-converting enzyme inhibitor use were independent predictors of postbypass vasodilatory shock (relative risks of 9.1 and 11.9, respectively). Vasodilatory shock was associated with inappropriately low serum arginine vasopressin concentrations (12.0 +/- 6.6 pg/mL). Retrospective analysis found 40 patients with postbypass vasodilatory shock who received low-dose arginine vasopressin infusions, resulting in increased mean arterial pressure and decreased norepinephrine requirements.
Low ejection fraction and angiotensin-converting enzyme inhibitor use are risk factors for postbypass vasodilatory shock, and this syndrome is associated with vasopressin deficiency. In patients exhibiting this syndrome after high-risk cardiac operations, replacement of arginine vasopressin increases blood pressure and reduces catecholamine pressor requirements.
体外循环可伴有血管扩张性低血压，需要使用血管升压药支持。我们之前发现精氨酸加压素在多种血管扩张性休克状态下是一种非常有效的血管升压药。我们调查了心脏手术患者总体人群中血管扩张性休克的发生率和临床预测因素，以及小剂量精氨酸加压素对心力衰竭患者该综合征的治疗效果。
对接受体外循环的患者（n = 145）进行前瞻性研究。记录术前射血分数、用药情况和围手术期血流动力学，并测量体外循环后血清精氨酸加压素水平。血管扩张性休克定义为平均动脉压低于70 mmHg、心脏指数大于2.5 L/min/m²且依赖去甲肾上腺素。通过逻辑回归分析研究血管扩张性休克的预测因素。对因左心室辅助装置置入或心脏移植接受体外循环后因血管扩张性休克接受精氨酸加压素输注的患者的血流动力学反应进行回顾性分析。
145例心脏手术患者中有11例（8%）符合体外循环后血管扩张性休克标准。通过多变量分析，射血分数低于0.35和使用血管紧张素转换酶抑制剂是体外循环后血管扩张性休克的独立预测因素（相对风险分别为9.1和11.9）。血管扩张性休克与血清精氨酸加压素浓度过低（12.0±6.6 pg/mL）有关。回顾性分析发现40例体外循环后血管扩张性休克患者接受了小剂量精氨酸加压素输注，导致平均动脉压升高，去甲肾上腺素需求量减少。
低射血分数和使用血管紧张素转换酶抑制剂是体外循环后血管扩张性休克的危险因素，且该综合征与加压素缺乏有关。在高危心脏手术后出现该综合征的患者中，补充精氨酸加压素可升高血压并减少儿茶酚胺类血管升压药的需求量。
