垂体后叶素与去甲肾上腺素治疗感染性休克比较的临床研究

目的 探讨与去甲肾上腺素(NE)相比,垂体后叶素能否降低感染性休克患者28d病死率.方法 本研究为前瞻性、随机、开放标记的临床对照研究,139例多巴胺用量超过5μg·kg-1· min-1的感染性休克患者按随机原则分为两组.两组综合治疗原则和方法相同,同时研究组联合使用垂体后叶素0.017～0.042 U/min( 1.0～ 2.5 U/h),如患者血流动力学仍不稳定,再加用NE以达到目标血压;对照组以NE维持血流动力学稳定.结果 139例纳入研究的患者中,66例纳入研究组,73例纳入对照组.两组基线时血流动力学和人口统计学治疗相匹配;研究组和对照组28 d总病死率没有明显差异(40.9％比46.6％,P＞0.05).将患者以急性生理学与慢性健康状况评分系统Ⅱ(APACHEⅡ)评分25分为界,发现APACHEⅡ评分＜25分的患者中,研究组28 d病死率显著低于对照组[ 10.3％( 3/29)比35.7％(10/28),P＜ 0.05].研究组与对照组在重症监护病房(ICU)住院时间[d:5(3,8)比5(3,8)]、机械通气时间[d:4.0(2.8,6.0)比4.0( 2.0,5.0)]上没有明显差异(均P＞0.05).使用垂体后叶素24h后,研究组NE用量(.μg/min:7.99±5.02比10.12±5.12)和心率(次/min:93.27±7.84比108.45±12.31)明显低于对照组(均P＜0.05),肌酐[μmol/L:87.5( 62.8,157.0)比76.0(52.5,117.0)]和乳酸(mmol/L:3.72±2.47比3.53±1.86)水平无明显差异(均P＞0.05),两组糖皮质激素(43.9％比31.5％)和小剂量肝素(42.4％比41.1％)使用率相似(均P＞0.05).结论 NE联合使用垂体后叶素可显著减少患者NE用量,减慢心率.尽管垂体后叶素不降低感染性休克总病死率,但对于APACHEⅡ评分＜25分的患者,小剂量垂体后叶素与儿茶酚胺类药物联合使用可降低患者28 d病死率.

A clinical study of pituitrin versus norepinephrine in the treatment of patients with septic shock

Objective To investigate whether pituitrin can lower 28-day mortality as compared with treatment with norepinephrine (NE) in patients with septic shock.Methods Randomized,controlled,open-label trial was conducted.One hundred and thirty-nine septic shock patients with dopamine requirements exceeding 5 μg· kg-1· min-1 were divided at random into two groups as the study group and control group.All patients enrolled were treated by the same treatment principle and measures.In patients of study group injection of pituitrin 0.017-0.042 U/min ( 1.0-2.5 U/h) was given,and if hemodynamics was still unstable,catecholamines was added to obtain the target blood pressure; while in the control group catecholamines was given to maintain stability of hemodynamics.Results Among 139 patients enrolled in the study,66 composed of the clinical study group and 73 in the control group.The main principle of the treatment in the two groups was similar.There was no significant difference in overall 28-day mortality rate between study group and control group (40.9％ vs.46.6％,P＞0.05).In patients whose acute physiology and chronic health evaluation Ⅱ ( APACHE Ⅱ ) score was less than 25,the mortality of study group was significantly lower than that of control group [ 10.3％ ( 3/29 ) vs.35.7％ ( 10/28 ),P＜0.05 ].The length of stay in intensive care unit [ ICU,days: 5(3,8) vs.5(3,8)],and duration of mechanical ventilation [days: 4.0 (2.8,6.0) vs.4.0 (2.0,5.0)] were similar in two groups (both P＞0.05).The dosage of NE (μg/min: 7.99 ±5.02 vs.10.12 ±5.12) and heart rate (beat/min: 93.27 ± 7.84 vs.108.45 + 12.31 ) were significantly lower in study group compared with that of control group (both P＜0.05 ).Serum creatinine and lactate levels in the two groups were similar at baseline,and creatinine [ μmol/L:87.5 (62.8,157.0 ) vs.76.0 (52.5,117.0) ] and lactate level (mmol/L: 3.72 ± 2.47 vs.3.53 ± 1.86) were still similar in two groups 24 hours later (all P＞0.05 ).The rate of use of glucocorticoid (43.9％ vs.31.5％ ) and heparin in small dosage (42.4％ vs.41.1％) had no significant difference between two groups (bothP＞0.05).Conclusions Combined use of pituitrin in patients with septic shock can reduce the dosage of catecholamines,and decrease the heart rate.Although it can not lower the overall mortality of septic shock,among patients with less severity whose APACHE Ⅱ score lower than 25,low-dose pituitrin in conjunction with catecholamine vasopressors can reduce 28-day mortality.