曲前列尼尔联合西地那非在室间隔缺损合并肺动脉高压围术期的应用

目的 探讨围术期采用曲前列尼尔联合西地那非治疗先天性心脏病室间隔缺损(VSD)合并肺动脉高压(PAH)患儿的疗效和预后.方法 回顾性分析2018年1月至2019年1月在本院诊断VSD合并PAH,择期行开胸心脏手术患儿,根据围术期除曲前列尼尔基础上是否联用西地那非治疗,分为单药治疗组及联用治疗组.结果 共纳入患儿48例,...     

持续静脉输注Treprostinil的护理

通过介绍国外Treprostinil持续静脉榆注治疗NYHA Ⅱ～Ⅳ级肺动脉高压(PAH)患者的护理,包括配制和应用Treprostinil的方法,输注前加强对患者及家属的健康教育,认真评估PAH的临床表现,观察药物的不良反应并做好相应处理,以使该药引进我国后护理人员能快速掌握治疗护理方法.     

Treatment of pulmonary arterial hypertension: the role of prostacyclin and prostaglandin analogs

Pulmonary arterial hypertension is a progressive, fatal disease characterized by elevated pulmonary arterial pressure ≥25 mm Hg and normal pulmonary capillary wedge pressure ≤ 5 mm Hg. Physiological features of pulmonary arterial hypertension are characterized clinically by the presence of pre-capillary pulmonary hypertension not caused by other conditions such as lung diseases or chronic thromboembolic pulmonary hypertension. There are several therapies currently available that have been shown to improve hemodynamics and improve outcomes in patients with pulmonary arterial hypertension. These therapies include synthetic prostacyclin and prostaglandin analogs, endothelin receptor antagonists, and phosphodiesterase-5 inhibitors. Multiple prostacyclin and prostaglandin analog formulations are currently in use (both branded and generic), available for parenteral, inhaled, or oral administration. This review discusses the pharmacology, clinical effects, and routes of administration of prostacyclin and prostaglandin analogs, emphasizing the advantages and disadvantages of each from the clinical perspective.     

Cost-minimization analysis of treprostinil vs. epoprostenol as an alternate to oral therapy non-responders for the treatment of pulmonary arterial hypertension

ABSTRACT

Introduction: Idiopathic pulmonary arterial hypertension (IPAH) is associated with substantial morbidity and mortality. Treprostinil was compared to epoprostenol for the economic impact of treating IPAH patients who failed or were not candidates for bosentan.

Methods: The model was a cost-minimization analysis, assuming clinical equivalence was achieved by proper dosing of both drugs, in terms of survival and surrogate measures. Two theoretical cohorts of 270 patients were treated with subcutaneous treprostinil and intravenous epoprostenol, and were evaluated over 3 years using a spreadsheet model. Annual survival rates were estimated for the cohorts so that at endpoint 114 (42%) patients survived in both groups. The model utilized resource valuation data for medication and supply costs from Medicare; hospital, consultation, surgical, and diagnostic procedural fees from North Carolina hospitals; and costs to treat adverse events from published sources. Costs were obtained from standard lists and were presented as 2003 US dollars, discounted at 3%. Sensitivity analyses were performed testing all model uncertainties.

Results: In the base case analysis, treprostinil demonstrated savings of $22?701 and $37?433 per patient over 1- and 3‐year time horizons, respectively. The greatest savings came from reduced or minimal hospitalizations attributed to the dose titration and treatment of adverse events, such as sepsis, associated with epoprostenol and its delivery system. Probabilistic sensitivity analyses resulted in average 3‐year cost-savings of $41?051 (Standard Deviation = $13?902) per patient.

Conclusions: By initiating and continuing treatment with treprostinil over a 3‐year period, the economic burden associated with IPAH may be reduced compared to treatment with epoprostenol. The greatest saving with treprostinil was attributed to decreased sepsis.     

Alta incidencia de bacteriemia por bacilos gramnegativos en pacientes con hipertensión pulmonar tratados con treprostinil por vía intravenosa

Introduction

An excessive risk for bacteremia has recently been reported in patients with pulmonary arterial hypertension (PAH) treated with intravenous treprostinil. We aimed to assess this association in a cohort of patients from a Spanish referral center.

Patients and methods

We performed a retrospective cohort study that included 55 patients diagnosed with PAH who received a continuous intravenous infusion of a prostanoid (epoprostenol or treprostinil) for ≥ 1 month at our center between January 1991 and December 2011. The risk factors associated with the incidence of bacteremia were analyzed with the log-rank test.

Results

After a total follow-up of 64,453 treatment days, we found 12 episodes of bacteremia: Staphylococcus aureus (5 episodes), non-fermenting gram-negative bacilli (4 episodes), other gram-positive cocci (2 episodes), and Enterobacter cloacae (one episode). The incidence of bacteremia was 0.118 episodes per 1,000 treatment days in patients receiving epoprostenol versus 0.938 episodes per 1,000 treatment-days in patients receiving treprostinil (P = .0037). All episodes of bacteremia due to Gram-negative bacilli were diagnosed in patients on treprostinil. In the univariate analysis the treatment with intravenous treprostinil was associated with the incidence of bacteremia (hazard ratio: 4.09; 95% confidence interval: 1.24-14.53), although the low number of events prevented us from performing a multivariate analysis.

Conclusions

Therapy with intravenous treprostinil is associated with a higher risk for bacteremia, especially due to non-fermenting Gram-negative bacilli. This association should be taken in consideration when choosing empirical antibiotic therapy for patients with PAH and sepsis.     

曲前列尼尔治疗Fontan术后早期失代偿患儿的临床疗效及安全性北大核心CSCD

目的探讨曲前列尼尔治疗Fontan术后早期失代偿患儿的临床疗效及安全性。方法回顾性分析2017年12月至2020年6月阜外华中心血管病医院使用曲前列尼尔注射液治疗的16例Fontan术后早期失代偿患儿的临床资料,16例患儿中男5例(31.2%),女11例(68.8%);年龄(4.6±1.2)岁,体质量(16.0±2.1)kg。记录治疗前、治疗3 h、24 h、48 h及72 h中心静脉压(CVP)、心率(HR)、收缩压(SBP)、中心静脉血氧饱和度(ScvO_(2))、乳酸(Lac)、氧合指数、B型利钠肽(BNP)变化;观察曲前列尼尔治疗Fontan术后早期失代偿患儿的近期疗效[病死率、机械通气时间、重症监护室(ICU)时间]。采用配对t检验比较不同时间点上述指标。记录用药过程中的不良反应。结果16例患儿机械通气中位时间9(5,22)h,ICU滞留中位时间2(1,12)d。用药72 h后,患儿CVP、Lac、BNP、HR下降,CVP从(16±5)mmHg(1 mmHg=0.133 kPa)降至(11±2)mmHg(P<0.001),Lac从(6.8±3.2)mmol/L降至(3.2±1.2)mmol/L(P=0.002),BNP从(980±223)ng/L降至(250±120)ng/L(P<0.001),HR从(150±20)次/min降至(125±16)次/min(P=0.002);SBP、ScvO_(2)、氧合指数上升:SBP从(83±10)mmHg升至(98±12)mmHg(P<0.001),ScvO_(2)从0.53±0.13升至0.65±0.11(P=0.003),氧合指数从(200±72)mmHg升至(298±13)mmHg(P<0.001),差异均有统计学意义(均P<0.05)。死亡1例(6.3%),2例(12.5%)早期有一过性血压下降,1例(6.3%)出现恶心、呕吐,无其他不良反应。结论对于Fontan术后早期失代偿患儿,静脉应用曲前列尼尔能快速降低肺动脉压,有效改善循环状态及氧合,最终改善患儿预后。