小剂量精氨酸加压素治疗感染性休克的应用

感染性休克是高死亡率疾病。临床上亟需一种有效的血管活性药物，以改善组织灌注。本文综述了精氨酸加压素在感染性休克中的应用机制和临床疗效。     

小剂量精氨酸加压素治疗感染性休克的应用

感染性休克是高死亡率疾病。临床上亟需一种有效的血管活性药物,以改善组织灌注。本文综述了精氨酸加压素在感染性休克中的应用机制和临床疗效。     

精氨酸加压素在血管舒张陛休克治疗中的进展

精氨酸加压素(arginine vasopressin,AVP)是一种强有力的血管收缩药,又称为抗利尿激素,用于治疗血管舒张性休克时,可有效提升血压、增加尿量和减少儿茶酚胺用量.现就AVP在血管舒张性休克中的应用作一综述,对其在改善血液动力学、器官灌注、疾病转归等方面的作用进行评估.     

血管加压素研究进展

血管加压素(arginine vasopressin,AVP)与多种心血管疾病和肾脏疾病的发生相关,目前主要用于治疗严重的外周血管扩张性休克,对于常规儿茶酚胺治疗效果不佳的患者尤为有效。心血管外科术后部分患者体内存在血管加压素相对不足,给予外源性血管加压素能够降低心率、减少儿茶酚胺类的使用量和使用时间。早期应用小剂量的血管加压素可能有助于患者术后血流动力学的恢复,而不会造成并发症的发生。进一步的随机对照试验,将为血管加压素的合理使用和剂量、疗程选择提供依据。     

多巴酚丁胺联合加压素对感染性休克大鼠肠损伤的影响

目的观察不同强效升压药对感染性休克大鼠肠损伤的影响。方法健康雄性SD大鼠50只,体重250～300g,随机均分为五组:生理盐水组(NS组)、去甲肾上腺组(NE组)、多巴胺组(DA组)、精氨酸加压素组(AVP组)及多巴酚丁胺联合精氨酸加压素组(DOB+AVP组)。股静脉注射内毒素15mg/kg建立感染性休克模型后,静脉输注生理盐水10ml·kg-1·h-1进行容量复苏,同时分别输注等容NS、NE1μg·kg-1·min-1、DA10μg·kg-1·min-1、AVP0.04U·kg-1·min-1和DOB10μg·kg-1·min-1联合AVP0.04U·kg-1·min-1。调整实验组升压药剂量使MAP维持在90mmHg左右,4h后取肠组织测定TNF-α、IL-6、IL-10水平;显微镜下观察肠组织及线粒体的损伤程度。结果 DOB+AVP组和NE组肠组织中TNF-α、IL-6含量低于NS组、DA组和AVP组(P<0.05)。IL-10含量各组之间差异无统计学意义。DOB+AVP组肠组织和线粒体损伤程度轻于其它四组。结论 DOB联合AVP治疗感染性休克时,可减轻肠组织炎症反应、缓解肠组织和线粒体损伤。     

一氧化氮合成酶抑制药在抗感染性休克中的应用

NO生成过多是导致感染性休克中血压下降的主要原因之一。本文综述NO合成酶抑制药在抗感染性休克中的作用。     

一氧化氮合成酶抑制药在抗感染性休克中的应用

ＮＯ生成过多是导致感染性休克中血压下降的主要原因之一。本文综述ＮＯ合成酶抑制药在抗感染性休克中的作用。     

Arginine vasopressin vs. terlipressin in the treatment of shock states

The synthetic vasopressin analogue, terlipressin, is being increasingly used to treat catecholamine-resistant hypotension in septic shock and other conditions. While terlipressin holds some theoretical and anecdotal advantages over vasopressin, this has not been formally tested in prospective randomised trials. This review analyses the published literature and makes comparisons, where possible, between vasopressin and terlipressin.     

小剂量精氨酸加压素在血管扩张性休克病人中的应用

目的观察小剂量精氨酸加压素(arginine vasopressin,AVP)在血管扩张性休克病人治疗中的作用及其并发症。方法对17例血管扩张性休克病人进行了研究。病人均予儿茶酚胺类药物治疗,在充分容量治疗后加用小剂量AVP(<0.04U/min),在维持MAP≥65mmHg的基础上逐步调整儿茶酚胺类药物的剂量。记录AVP治疗前后的血流动力学参数、肾功能、儿茶酚胺类药物的用量、并发症及病人的预后。结果予小剂量AVP治疗后,病人HR和儿茶酚胺类药物的剂量均显著下降(P<0.01),MAP显著升高(P<0.05),心脏指数(CI)显著下降(P<0.01),每搏量指数(SVI)和周身血管阻力指数(SVRI)均显著升高(P<0.05),尿量显著增加(P<0.01),血肌酐(Cr)显著下降(P<0.01),肌酐清除率(CL)显著升高(P<0.01)。结论加用小剂量AVP治疗可明显改善血管扩张性休克病人的血流动力学,可减少儿茶酚胺类药物的需要量,并改善肾功能。     

Arginine vasopressin in the treatment of vasodilatory septic shock

Vasodilatory septic shock is characterized by profound vasodilation of the peripheral circulation, relative refractoriness to catecholamines and a relative deficiency of the posterior pituitary hormone, vasopressin. Arginine vasopressin is effective in restoring vascular tone in vasodilatory septic shock and may be associated with decreased mortality in less severe septic shock as well as improved mortality and decreased renal failure in septic shock patients at risk for renal failure.     

Community-acquired septic shock: early management and outcome in a nationwide study in Finland

AIM: To determine how the early treatment guidelines were adopted, and what was the impact of early treatment on mortality in septic shock in Finland. METHODS: This study was a sub-analysis of a prospective observational investigation of severe sepsis and septic shock in Finland (Finnsepsis). All patients with severe sepsis over 4 months in 24 intensive care units were included in the Finnsepsis study. Patients with community-acquired septic shock, admitted directly from the emergency department to the intensive care unit, were included in the sub-study. The following treatment targets were evaluated: measurement of lactate during the first 6 h; analysis of blood culture before antibiotics; commencement of antibiotics within 3 h; attainment of a mean arterial pressure of > or =65 mmHg, central venous pressure of > or =8 mmHg and central venous oxygen saturation of > or =70% or mixed venous oxygen saturation of > or =65% during the first 6 h. RESULTS: Of the 92 patients who fulfilled the inclusion criteria, six reached all treatment targets and 33 reached four or more targets (group > or =4). The hospital mortality of group > or =4 was 24% (8/33), compared with 42% (25/59) for those who reached three or fewer targets (group < or =3) (P= 0.08). The 1-year mortality rates of group > or =4 and group < or =3 were 36% and 59% (P= 0.04), respectively. In logistic regression analysis, a delayed initiation of antimicrobials was associated with an unfavourable outcome (P= 0.04). CONCLUSIONS: Compliance with international guidelines for the early treatment of septic shock was poor in Finnish hospitals. A failure to diagnose early and to start appropriate treatment was reflected in the high mortality. The delayed start of antibiotics was the most important individual variable leading to a high mortality in this nationwide study.     

Arginine vasopressin and serum nitrite/nitrate concentrations in advanced vasodilatory shock

BACKGROUND: Arginine-vasopressin (AVP) can successfully stabilize hemodynamics in patients with advanced vasodilatory shock. It has been suggested that inhibition of cytokine-induced nitric oxide production may be an important mechanism underlying AVP-induced vasoconstriction. Therefore, serum concentrations of nitrite/nitrate (NOx), the stable metabolite of nitric oxide, were measured in patients suffering from advanced vasodilatory shock treated with either AVP in combination with norepinephrine (NE) or NE alone. METHODS: This trial was a separate study arm of a previously published prospective, randomized, controlled study on the effects of AVP in advanced vasodilatory shock. Thirty-eight patients were prospectively randomized to receive a combined infusion of AVP (4 U h(-1)) and NE, or NE infusion alone. Serum NOx concentrations were measured at baseline, 24, and 48 h after randomization. The increase in mean arterial pressure during the first hour after study enrollment was documented in all patients. RESULTS: No difference in NOx concentrations was found between groups throughout the study period. AVP patients demonstrated a significantly greater increase in mean arterial pressure than NE patients (22 +/- 10 vs. 5 +/- 9 mmHg; P < 0.001). The magnitude of pressure response to AVP was not correlated with NOx concentrations before start of AVP infusion (Pearson's correlation coefficient, -.009; P = 0.971). CONCLUSION: Cardiovascular effects of AVP infusion in advanced vasodilatory shock are not mediated by a clinically relevant reduction in serum NOx concentrations. Therefore, hemodynamic improvement of patients in advanced vasodilatory shock during continuous infusion of AVP has to be attributed to other mechanisms than inhibition of nitric oxide synthase. In addition, the magnitude of pressure response to AVP is not correlated with baseline concentrations of NOx.     

感染性休克早期目标指导性治疗方案的应用体会

目的 为加强外科围手术期处理，观察应用早期目标指导性治疗方案（early goal directed therapy，EGDT）对感染性休克患者的救治效果。方法 运用EGDT使入ICU8h内的感染性休克患者的中心静脉压（CVP）、平均动脉压（MAP）和上腔静脉血氧饱和度（ScvO2）达标。结果 本组20例感染性休克患者，在8h内CVP达标20例，MAP达标20例，ScvO2达标16例。结论 应用EDGT治疗感染性休克有较好的理论基础和实用性，在限定的时间内使所有的目标值达标存在一定的困难。     

Role of terlipressin in the treatment of infants and neonates with catecholamine-resistant septic shock

The present paper is aimed at reviewing new findings on the use of terlipressin in children with septic shock. The level of evidence based on the data available in the literature is very low. Three series of cases and four isolated cases report on the use of terlipressin in children with catecholamine-refractory septic shock. The aggregated population represents 39 children. The dosages of boli vary from 7 microg/kg twice a day to 2 microg/kg every 4 hours. Low-dose continuous infusion has also been described. Terlipressin injection is associated with an approximately 30% increase in blood pressure. Mortality of these children with catecholamine refractory septic shock is 54%. The paucity of most reports does not make it possible to conclude on the global and microcirculatory effects of this treatment. Future studies are required before any recommendations on the use of terlipressin in children with septic shock can be made.     

吻合口瘘并发脓毒症休克危险因素分析

目的：探讨吻合口瘘患者并发脓毒症休克的危险因素。方法回顾性分析2008年1月至2014年7月于我科接受腹部大手术治疗后发生吻合口瘘患者的临床资料,根据是否并发脓毒症休克将患者分为脓毒症休克组和非脓毒症休克组,比较组间相关指标的差异,多因素回归分析探讨吻合口瘘并发脓毒症休克的危险因素。结果脓毒症休克组患者 APACHEⅡ评分较高,合并基础疾病、恶性疾病、输血等情况更为多见,平均动脉压较低,胰肠吻合比例较高,菌血症、MODS 发生率较高,住院时间较长,组间差异有统计学意义（P 均＜0．05）。多因素 Logistic 回归结果显示,恶性疾病、COPD／肝脏基础疾病、输血、菌血症、结肠-结肠吻合口瘘以及 APACHEⅡ评分＞15是吻合口瘘患者可能发生脓毒症休克的独立危险因子（OR 值均＞1．0,P ＜0．05）。结论恶性疾病、COPD／肝脏基础疾病、输血、菌血症、结肠-结肠吻合口瘘以及 APACHEⅡ评分＞15是吻合口瘘患者发生脓毒症休克的危险因素。