多巴胺与去甲肾上腺素对感染性休克患者疗效的比较

选择我院急诊科2009年10月~2013年9月收治的感染性休克患者50例为研究对象。两组患者在进行充分液体复苏、抗感染、纠酸、肾上腺皮质激素治疗基础上,A组微量泵入药物多巴胺1~15μg/(kg·min),B组微量泵入药物去甲肾上腺素0.03~2μg/(kg·min),维持患者平均动脉压在75mm Hg或以上。经过治疗后比较两组患者的动脉血乳酸浓度水平,发现两组患者的数值均出现了不同程度的降低,但B组患者的动脉血乳酸浓度水平要显著低于A组,差异有统计学意义(P0.05);B组的6、12和24h动脉血乳酸清除率要高于A组患者,差异也有统计学意义(P0.05);比较两组患者的平均动脉压可以发现,B组患者的平均动脉压亦高于A组,差异有统计学意义(P0.05),去甲肾上腺素比多巴胺能更有效地改善感染性休克患者的血流动力学并明显降低患者的动脉血乳酸浓度,加快了动脉血中的乳酸清除,并进一步显著改善了组织器官的缺血缺氧。     

多巴胺与去甲肾上腺素治疗感染性休克患者的临床疗效比较

目的比较多巴胺与去甲肾上腺素治疗感染性休克的临床疗效。方法将我院收治的86例感染性休克患者随机分为多巴胺治疗组(DA组)和去甲肾上腺素治疗组(NE组)各43例,观察两组患者治疗6h后的动脉血乳酸、平均动脉压(MAP)以及混合静脉血氧饱和度(SvO2)的变化情况。结果治疗后NE组患者的动脉血乳酸、MAP以及SvO2水平较DA组有显著改善,组间差异有统计学意义(P<0.05),NE组疗效优于DA组。结论去甲肾上腺素治疗感染性休克的临床疗效优于多巴胺。     

去甲肾上腺素对感染性休克患者血流动力学的影响效果

观察去甲肾上腺素对感染性休克患者血流动力学的影响效果,为感染性休克的防治措施提供依据。选择我科收治的118例感染性休克患者,根据患者的入组顺序以及自身意愿进行分组,分为观察组与对照组,其中予以去甲肾上腺素治疗者为观察组,予以多巴胺治疗者为对照组,各59例。治疗后观察两组患者的有效性及血流动力学变化。与对照组比较,观察组患者的HR、CI降低明显,SVRI、乳酸清除率、Sv O2则升高明显,差异均具统计学意义(P0.05)。观察组的病死率虽低于对照组,但差异不具有统计学意义(P0.05)。相较于多巴胺,去甲肾上腺素可较好的改善感染性休克患者的血流动力学,提高治疗有效性。     

去甲肾上腺素微量泵入对重症感染性休克患者血流动力学及血清乳酸的影响

目的探究去甲肾上腺素微量泵入对重症感染性休克患者血流动力学及血清乳酸的影响。方法选取我院收治的62例重症脓毒性休克患者,随机分为对照组和试验组各31例。对照组予以多巴胺微量泵经中心静脉泵入,并根据患者血压调整剂量,试验组在对照组基础上予以去甲肾上腺素微量泵入治疗。比较两组患者血流动力学指标、血清乳酸水平、乳酸清除率以及死亡率。结果治疗后12h、24h两组患者HR均降低,CI、MAP、CVP、PAWP水平均升高,动脉血乳酸水平均降低,差异有统计学意义(P0.05);试验组HR显著低于对照组,差异有统计学意义(P0.05);试验组CI、MAP、CVP、PAWP水平显著高于对照组,差异有统计学意义(P0.05);试验组动脉血乳酸水平显著低于对照组,差异有统计学意义(P0.05);试验组死亡率低于对照组,但比较无差异(P0.05)。结论去甲肾上腺素微量泵入能够显著改善重症感染性休克患者血流动力学,加速乳酸清除率,提高患者存活率,适宜临床推广应用。     

特利加压素与去甲肾上腺素对≥80岁感染性休克患者平均动脉压及休克指数的影响

目的探讨特利加压素与去甲肾上腺素对≥80岁感染性休克患者平均动脉压及休克指数的影响。方法选取2012年1月至2014年1月收治的50例≥80岁感染性休克患者,依据随机数字表法将这些患者分为两组,即观察组和对照组,每组25例。给予观察组患者特利加压素联合去甲肾上腺素治疗,给予对照组患者多巴胺联合去甲肾上腺素治疗。详细记录两组患者的心率、平均动脉压、休克指数、血尿素氮、肌酐、肌醉清除率(CCr)、滤过水排泄分数(FEH20)、滤过钠排泄分数(FENa)等指标。结果除血尿素氮、肌酐两组之间的差异均无显著性(P0.05)外,治疗后两组其他各项指标均有改善,且观察组患者的平均动脉压、尿量均明显比对照组高,心率、休克指数均明显比对照组低,UV、CCr、FEH20均明显比对照组高,FENa明显比对照组低(P0.05)。术后并发症发生率方面观察组(16.0%)明显低于对照组(40.0%)(P0.05)。结论特利加压素比多巴胺更能有效提升≥80岁感染性休克患者的平均动脉压,并降低其休克指数。     

去甲肾上腺素联合酚妥拉明治疗感染性休克的临床疗效分析

目的:探究去甲肾上腺素联合酚妥拉明治疗感染性休克的临床疗效。方法:将在本院接受治疗的42例感染性休克患者,依据治疗方式的不同分为联合用药组A,予以去甲肾上腺素联合酚妥拉明治疗;联合用药组B,予以多巴胺联合酚妥拉明治疗。比较两组患者用药后0²4h内的心率、平均动脉压、休克指数、动脉血乳酸的变化。结果:治疗24h后,两组患者的各项指标均得到有效改善;而A组的血乳酸浓度在用药24h后,明显低于B组(P<0.05),其他指标如心率、休克指数等的改善程度优于B组(P<0.05)。结论:去甲肾上腺素联合酚妥拉明治疗感染性休克在改善组织缺血、提高平均动脉压等方面均有积极意义,值得推广应用。     

去甲肾上腺素联合多巴酚丁胺对感染性休克患者心室功能影响的研究

目的观察去甲肾上腺素（NE）、去甲肾上腺素联合多巴酚丁胺（NE＋Dobu）对感染性休克患者心室功能的影响。方法符合感染性休克诊断标准的17例患者经过积极的液体复苏后，随机应用血管活性药物，观察增加心排指数（CI）、体循环阻力指数（SVRI）、肺循环阻力指数（PVRI）、左室每搏功指数（LVSWI）、右室每搏功指数（RVSWI）的变化。结果去甲肾上腺素、去甲肾上腺素＋多巴酚丁胺都能提高血压，增加心排指数（CI）、体循环阻力指数（SVRI）、左室每搏功指数（LVSWI）、氧输送（DO2），与基础值比较差异有显著性意义（P〈0．05）；对降低PVRI、增加RVSWI去甲肾上腺素＋多巴酚丁胺比单独去甲肾上腺素明显，但差异没有统计学意义（P〉0．05）。结论多巴酚丁胺和去甲肾上腺素联合既能明显改善左心功能，对右心功能也有一定的改善作用，是治疗感染性休克患者理想的血管活性药。     

小剂量血管加压素与去甲肾上腺素对感染性休克的治疗效果

目的探讨小剂量血管加压素(AVP)与去甲肾上腺素(NE)治疗感染性休克的临床效果。方法选取2014年10月至2016年9月感染性休克患者102例,按照治疗方案分为两组,每组51例。对照组给予去甲肾上腺素治疗,研究组给予小剂量AVP与去甲肾上腺素治疗,比较两组乳酸清除率及血流动力学、肾功能指标水平。结果治疗后24 h,乳酸清除率、HR、MAP、肾功能指标研究组优于对照组,差异有统计学意义(P<0.05)。结论感染性休克应用AVP与NE治疗,可有效改善患者血流动力学,提高乳酸清除率,缓解肾功能损伤。     

去甲肾上腺素联合多巴酚丁胺对感染性休克患者胃粘膜灌注的作用

目的：观察多巴胺（Dopa)、去甲肾上腺素（NE）、去甲肾上腺素联合多巴酚丁胺（NE＋Dobu）对感染性休克患者胃肠道灌注的影响。方法：符合感染性休克诊断标准的13例患者经过积极的液体复苏后，随机应用血管活性药物，观察胃粘膜内pH(pHi）、胃粘膜与动脉血二氧化碳分压差（△PCO2）的变化。结果：多巴胺、去甲肾上腺素，去甲肾上腺素＋多巴酚丁胺都能提高血压，增加心排指数（CI）、体循环阻力指数（SVRI）、左室每搏功指数（LVSWI）、氧输送（DO2），与基础值比较差异有显著性意义（P＜0．05）；但对胃pHi,△PCO2的改善去甲肾上腺素＋多巴酚丁胺比单独去甲肾上腺素明显，比多巴胺更好，差异有显著性意义（P＜0．05）。结论：多巴酚丁胺和去甲肾上腺素联合即能增加CI、SVRI、LVSWI、DO2，又能改善胃pHi, △PCO2，是治疗感染性休克患者理想的血管活性药。     

感染性休克患者中心静脉血和混合静脉血氧饱和度缺乏一致性

目的感染性休克患者的中心静脉血氧饱和度(SCVO2)与混合静脉血氧饱和度(SVO2)的相关性分析。方法符合感染性休克诊断的25例患者分成重症肺炎组和腹腔感染组。所有患者均留置Swan-Ganz导管,从入科开始,每隔6小时不分顺序抽取中心静脉血和混合静脉血,进行血气分析,获取SCVO2和SVO2,对数据进行统计分析。结果所有患者及重症肺炎组、腹腔感染组的SCVO2和SVO2比较,差异均有统计学意义(t分别=4.90、4.29、7.21,P均<0.05),25例感染性休克患者SCVO2和SVO2的差异均值为(5.94±6.78)%,SCVO2比SVO2高,12例重症肺炎患者的SCVO2和SVO2的差异均值为(5.45±6.89)%,SCVO2比SVO2高,13例腹腔感染组患者的SCVO2和SVO2的差异均值为(7.90±6.22)%,SCVO2比SVO2高,重症肺炎组及腹腔感染组SCVO2和SVO2之间相关系数,差异有统计学意义(Δz=2.05,P<0.05)。结论感染性休克患者血流动力学不稳定时,尽量不用SCVO2替代SVO2。     

纳洛酮联合血必净治疗感染性休克的临床疗效及作用机制研究

目的:观察纳洛酮联合血必净治疗感染性休克的临床疗效,并探讨其可能的作用机制.方法:对45例感染性休克患者,随机分为2组,治疗组23例,对照组22例,治疗组患者在常规抗休克治疗的基础上加用纳洛酮联合血必净治疗.结果:治疗组总有效率为91.3％,明显好于对照组72. 7％(P＜0.05),监测血液动力学变化△CVP、△MAP、△UA、△ScvO2治疗组明显好于对照组(P＜0.05).治疗组MODS的发生率为30.4％(7/23).病死率为13.0％(3/23),对照组MODS的发生率为54.6％(12/22),病死率为27.3％(6/22),两组MODS的发生率比较差异有统计学意义(P＜0.05).结论:纳洛酮联合血必净能够显著改善感染性休克患者的病情,提高生存率.作用机制可能与纳洛酮能拮抗β内啡肽,血必净能降低内毒素的水平有关.     

Effect of norepinephrine on the outcome of septic shock

OBJECTIVE: Despite increasingly sophisticated critical care, the mortality of septic shock remains elevated. Accordingly, care remains supportive. Volume resuscitation combined with vasopressor support remains the standard of care as adjuvant therapy, and many consider dopamine to be the pressor of choice. Because of fear of excessive vasoconstriction, norepinephrine is considered to be deleterious. The present study was designed to identify factors associated with outcome in a cohort of septic shock patients. Special attention was paid to hemodynamic management and to the choice of vasopressor used, to determine whether the use of norepinephrine was associated with increased mortality. DESIGN: Prospective, observational, cohort study. SETTING: Intensive care unit of a university hospital. PATIENTS: Ninety-seven adult patients with septic shock. MEASUREMENTS AND MAIN RESULTS: Data from these patients were examined to select variables independently and significantly associated with outcome during the hospital stay. Nineteen clinical, biological, and hemodynamic variables were collected at study entry or during the first 48-72 hrs and analyzed for each patient. A stepwise logistic regression analysis and a model building strategy were used to identify variables independently and significantly associated with outcome. The overall hospital mortality was 73% (71 patients). Five variables were significantly associated with outcome. One factor was strongly associated with a favorable outcome: the use of norepinephrine as part of the hemodynamic support of the patients. The 57 patients who were treated with norepinephrine had significantly lower hospital mortality (62% vs. 82%, p < .001; relative risk = 0.68; 95% confidence interval = 0.54-0.87) than the 40 patients treated with vasopressors other than norepinephrine (high-dose dopamine and/or epinephrine). Four variables were associated with a poor outcome and significantly higher hospital mortality: pneumonia as a cause of septic shock (82% vs. 61%, p < .03; relative risk = 1.47; 95% confidence interval = 1.07-1.77), organ system failure index < or = 3 (92% vs. 60%, p < .001; relative risk = 1.47; 95% confidence interval = 1.17-1.82), low urine output at entry to the study (88% vs. 60%, p < .01; relative risk = 1.44; 95% confidence interval = 1.06-1.87), and admission blood lactate concentration > 4 mmol/L (91% vs. 63%, p < .01; relative risk = 1.60; 95% confidence interval = 1.27-1.84). CONCLUSIONS: Our results indicate that the use of norepinephrine as part of hemodynamic management may influence outcome favorably in septic shock patients. The data contradict the notion that norepinephrine potentiates end-organ hypoperfusion, thereby contributing to increased mortality. However, the present study suffers from some limitation because of its nonrandomized, open-label, observational design. Hence, a randomized clinical trial is needed to clearly establish that norepinephrine improves mortality of patients with septic shock, as compared with high-dose dopamine or epinephrine. Pneumonia as the cause of septic shock, high blood lactate concentration, and low urine output on admission are strong indicators of a poor prognosis. Multiple organ failure is confirmed as a reliable predictor of mortality in septic patients.     

High-dose naloxone: pharmacokinetics in patients in septic shock

Naloxone, a commonly used narcotic antagonist, may be beneficial in reversing the hemodynamic alterations seen in septic shock. In normal subjects, naloxone pharmacokinetics are characterized by rapid distribution and elimination. We investigated the pharmacokinetics of high-dose naloxone in four patients with septic shock and multiorgan failure. The pharmacokinetics of naloxone in these patients can be described by a two-compartment model with a rapid alpha distribution similar to that observed in normal humans. However, in these critically ill patients there was virtually no drug elimination as levels were followed for 5 h post-termination of a 6-h infusion of 2.4 mg/kg X h. This dramatic accumulation of naloxone may explain why responses have been reported by others to small doses of naloxone in septic shock patients. No significant side-effects were seen in our patients with plasma naloxone levels as high as 3.78 micrograms/ml. Caution is warranted when one administers naloxone to patients whose ability to eliminate this drug is minimal.     

多巴胺及去甲肾上腺素对脓毒性休克患者血流动力学及组织氧合的影响

目的探讨多巴胺（DA）及去甲肾上腺素（NE）在治疗脓毒性休克过程中对血流动力学及组织氧合的影响。方法选择脓毒性休克患者16例，按随机原则分别给予DA（DA组）或NE（NE组）升压治疗，分别于观察1、2、3和4h末检测血流动力学指标[心率（HR）、平均动脉压（MAP）、心排血指数（CI）、每搏指数（SI）、体循环阻力指数（SVRI）、心脏加速指数（ACI）、左室作功指数（LCWI）、胸腔内液体水平（TFC）]，混合静脉血氧饱和度（SvO2），血乳酸（Lac）及每小时尿量（UV）；于4h末测定肌酐清除率（CCr）。结果①两组各时间点MAP、SI及TFC比较差异均无统计学意义；而LCWI于2h末显示差异有统计学意义（P=0．031）。DA组的HR、CI及ACI明显高于NE组，而SVRI明显低于NE组（P〈0．05或P〈0．01）。说明DA及NE均有很好的升压效果；DA在增加全身氧输送方面优于NE，但使HR加快的作用可能在一定程度上限制了其使用。②两组各时间点SvO2比较差异无统计学意义；而DA组的血Lac水平明显高于NE组（P均〈0．05）。说明在增加内脏灌注及组织氧合方面，NE可能优于DA。③DA组各时间点的uV明显高于NE组（P〈0．05或P〈0．01）。DA组于4h末CCr明显高于NE组（P=0．023），说明DA有明显增加尿量及CCr的作用，对肾功能可能有一定的保护作用。结论对于有少尿和（或）肾功能不全的脓毒性休克患者，应用DA可能是较好的选择，而对于有快速型心律失常或组织缺氧严重的脓毒性休克患者NE可能是更好的选择。     

Early versus delayed administration of norepinephrine in patients with septic shock

Introduction

This study investigated the incidence of delayed norepinephrine administration following the onset of septic shock and its effect on hospital mortality.

Methods

We conducted a retrospective cohort study using data from 213 adult septic shock patients treated at two general surgical intensive care units of a tertiary care hospital over a two year period. The primary outcome was 28-day mortality.

Results

The 28-day mortality was 37.6% overall. Among the 213 patients, a strong relationship between delayed initial norepinephrine administration and 28-day mortality was noted. The average time to initial norepinephrine administration was 3.1 ± 2.5 hours. Every 1-hour delay in norepinephrine initiation during the first 6 hours after septic shock onset was associated with a 5.3% increase in mortality. Twenty-eight day mortality rates were significantly higher when norepinephrine administration was started more than or equal to 2 hours after septic shock onset (Late-NE) compared to less than 2 hours (Early-NE). Mean arterial pressures at 1, 2, 4, and 6 hours after septic shock onset were significantly higher and serum lactate levels at 2, 4, 6, and 8 hours were significantly lower in the Early-NE than the Late-NE group. The duration of hypotension and norepinephrine administration was significantly shorter and the quantity of norepinephrine administered in a 24-hour period was significantly less for the Early-NE group compared to the Late-NE group. The time to initial antimicrobial treatment was not significantly different between the Early-NE and Late-NE groups.

Conclusion

Our results show that early administration of norepinephrine in septic shock patients is associated with an increased survival rate.     

2种心排量监测方法在重症感染性休克患者中的应用

目的比较无创心排量监测(non-invasive cardiac output monitoring,NICOM)与脉搏指示连续心排量(pulseindicated continuous cardiac output,Pi CCO)监测2种方法测定重症感染性休克患者血流动力学参数的差异及相关性,为护士参与开展重症患者床旁无创心排量监测提供依据。方法选取2017年4月—12月收入北京某三级甲等医院ICU需进行血流动力学监测的感染性休克患者作为研究对象,分别对同一患者采用NICOM和Pi CCO 2种方式监测患者心输出量和每搏量变异度,比较2种方法的差异和相关性。结果共纳入感染性休克患者31例,男19例,女12例,其中NICOM测得心输出量为5.10(4.35,6.50)L/min,Pi CCO测得心输出量为4.89(4.34,6.23)L/min,两种方法比较,差异无统计学意义(Z=-0.786,P=0.430);NICOM测得每搏量变异度为13.00(11.00,16.00),Pi CCO测得每搏量变异度为12.00(9.00,15.00),两种方法比较,差异有统计学意义(Z=-2.6...     

Effects of norepinephrine on right ventricular function in septic shock patients

Objective To study the effects of norepinephrine on right ventricular function in patients with hyperdynamic septic shock.Design Prospective, open study.Setting A 15 bed ICU in a university hospital.Patients 9 patients with hyperdynamic septic shock (SBP<90 mmHg, Cl4l·min^–1·m^–2, SVRI850 dynes·s·cm^–5m^–2 and oliguria).Interventions Plasma volume expansion was used to correct a suspected volume deficit and then, norepinephrine infusion was started and titrated to restore systemic blood pressure to the normal range (mean infusion rate: 1.1±0.2 mcg·kg^–1·min^–1). Norepinephrine was the only vasoactive agent used in these patients.Measurements and results A modified Swan-Ganz catheter mounted with a fast response thermistor was inserted in each patient, allowing repeated measurements of RVEDVI and RVEF. At time of inclusion to the study, all but one patient had elevated MPAP (23±4 mmHg) and RVEF50%, and all patients had RVEDVI90 ml·m^–2. During norepinephrine infusion, MAP increased from 51±9 to 89±10 mmHg (p<0.0001), PVRI increased from 204±35 to 286±63 dynes·s·cm^–5·m^–2 (p<0.05), and despite this increase in right ventricular afterload, no detrimental effect in RVEF (36±11 to 36±10%) or in RVEDVI (116±30 to 127±40 ml·m^–2) was observed. A Frank-Starling relationship for the right ventricle was constructed by plotting an index of ventricular performance (RVSWI) against an index of ventricular preload (RVEDVI). A significant upward shift to the right of the relationship was observed during norepinephrine infusion.Conclusion It was concluded that norepinephrine exerted a favourable effect on right ventricular function.Work done at Sainte Marguerite Hospital, Marseille, France     

Endotoxaemia in patients with severe sepsis or septic shock

Objective: To examine the incidence and the bacteriological and clinical significance of endotoxaemia in ICU patients with severe sepsis or septic shock. Design: Prospective review. Setting: A 15-bed general ICU in a university hospital. Patients: One hundred sixteen patients hospitalised in our ICU fulfilling Bone's criteria for severe sepsis or septic shock and with an available early endotoxin assay (chromogenic limulus assay). Interventions: None. Measurements and results: The clinical characteristics of the population were: age 63.6 ± 11.4 years; SAPS II: 45.4 ± 15.6; mechanical ventilation: 72.4 %; septic shock: 51.7 % (n = 60); bacteraemia: 28.4 % (n = 33); gram-negative bacteria (GNB) infection 47.4 % (n = 55); ICU mortality: 39.6 % (n = 46). Detectable endotoxin occurred in 61 patients (51.2 %; mean level: 310 ± 810 pg/ml). There was no relationship between detectable endotoxin and severity of infection at the moment of the assay. Endotoxaemia was associated with a higher incidence of bacteraemia (39.3 % vs 16.3 %; p = 0.01). There was a trend (p = 0.09) towards an association between positive endotoxin and gram-negative bacteraemia or GNB infection but this was non-significant. This relationship became significant only in the case of bacteraemia associated with GNB infection irrespective of the site of infection. Conclusion: Early detection of endotoxaemia appeared to be associated with GNB infection only in cases of bacteraemic GNB infection. Early endotoxaemia correlated neither to occurrence of organ dysfunction nor mortality in patients with severe sepsis or septic shock. This study suggests that the use of endotoxaemia as a diagnostic or a prognostic marker in daily practice remains difficult. Received: 28 September 1999 Final revision received: 31 January 2000 Accepted: 1 February 2000