去甲肾上腺素在脓毒症休克患者中的降阶梯使用

目的探讨脓毒症休克患者早期去甲。肾上腺素（NE）降阶梯治疗对早期目标导向治疗（EGDT）执行和预后的影响。方法收集重症监护病房（ICU）需NE治疗的脓毒症休克患者60例，按随机数字表法随机分成两组，每组30例，去除24h内死亡及合并心源性休克患者18例，两组均有21例最终入选。两组均根据EGDT进行目标液体复苏治疗，第一组为常规使用NE组（CNE组），即逐渐加量NE至血流动力学稳定；第二组为降阶梯NE组（DNE组），开始就给予NE0．5或1．0gg／（kg·min），血流动力学稳定后再逐渐减量。在治疗前对所有休克患者进行急性生理学与慢性健康状况评分系统Ⅱ（APACHE1I）评分，记录应用NE前及应用30min，2h，6h，12h，24h后心率（HR）、平均动脉压（MAP）、中心静脉压（CVP）、血乳酸值、中心静脉血氧饱和度（ScV02）。同时比较两组患者24h液量、急性肾损伤（AKI）、应用连续。肾脏替代治疗（CRRT）、急性呼吸窘迫综合征（ARDS）、应用镇静药物后出现血压下降和出现应激性溃疡的例数及28d内死亡例数。结果两组患者均可完成EGDT目标，MAP和CVP在用药30min和2h时，DNE组明显高于CNE组MAP：（72．3±5．5）VS（61．0±6．8）mmHg，（71．9±6．I）vs（66．1±6．2）mmHg；CVP：（10．3±1．9）VS（8．5±2．4）mmHg，（10．5±1．8）vj（8．74-2．2）mmHg；均P〈0．051。MAP和CVP在其他时间点上，两组差异无统计学意义（P〉0．05）。HR、血乳酸值、ScV02在各时间点差异均无统计学意义（P〉0．05）。24h心液量DNE组较CNE组减少（57084-934）VS（63524-1208）ml，P〈O．05]。应用镇静药物后血压下降的患者，DNE组较CNE组减少（6VS15，P〈O．05）。而两组患者在出现AKI、应用CRRT、ARDS和出现应激性溃疡的患者例数及28d内病死率方面差异无统计学意义（P〉0．05）。结论NE的降阶梯使用在脓毒症休克中更便于EGDT的执行，对重要脏器并未增加缺血风险，有利于复苏液体的控制。

De-escalation application of norepinephrine in treatment of patients with septic shock

Objective To determine the effects of early de-escalation application of norepinephrine （NE） on the performance of early goal-directed therapy （EGDT） and its prognosis in the treatment of septic shock patients. Methods A total of 60 patients with identified septic shock who required NE treatment in our intensive care unit from January 2011 to March 2013 were enrolled in this study. They were randomly divided into 2 groups, with 30 patients in each group. Ultimately, there were 21 patients in each group after 18 cases of death or complicated with cardiogenic shock within 24h were excluded. The 2 groups were treated according to the EGDT target fluid resuscitation. The patients in first group underwent of conventional NE therapy （CNE group）, with the dose of NE increased gradually till hemodynamics were stable. The patients in second group were given de-escalation application of norepinephrine（DNE group）, that was NE at 0.5 or lktg/（kg ± min） firstly till hemodynamic stabilization, and then followed by de-escalation therapy. All the shock patients were scored using Acute Physiology And Chronic Health Evaluation II （APACHE II ） scoring system before treatment. The heart rate （HR）, mean arterial pressure （MAP）, central venous pressure （CVP）, blood lactate, and central venous oxygen saturation （ScVO2） were recorded at the beginning and at 30 min, and 2, 6, 12 and 24h after the treatment of NE. At the same time, the amount of 24-hour fluid replacement, the incidences of acute kidney injury（AKI） and acute respiratory distress syndrome（ARDS）, continuous renal replacement therapy （CRRT）, decrease in blood pressure and stress ulcer after sedative drugs, and death within 28d were compared between the 2 groups. Results All patients achieved EGDT targets. MAP （72.3 ± 5.5）and （71.9 ± 6.1）mmHg] and CVP （10.3 ± 1.9） and （10.5 ± 1.8）mmHg] at 30 min and 2h respectively after treatment in DNE group were significantly higher than those in CNE group （61.0 ± 6.8） and （66.1 ± 6.2）mmHg, （8.5 ± 2.4） and （8.7 ± 2.2）mmHg, all P 〈 0.05] There was no significant difference in MAP and CVP at other time points between 2 groups （P 〉 0.05）. Neither was the HR, blood lactate, and ScVO2 between the 2 groups at all time points （P 〉 0.05）. The amount of 24-hour fluid replacement was lower in DNE group than in CNE group （5708 ± 934） vs （6352 ± 1208）ml, P〈 0.05]. There were less patients with lower blood pressure after sedative drugs in DNE group than in CNE group （6 vs 15, P〈 0.05）. The incidences of AKI, ARDS, stress ulcer, CRRT, and the mortality within 28 days had no significant difference between 2 groups （P 〉 0.05）. Conclusion The de-escalation application of NE is more convenient for EGDT in treatment of septic shock, which does not increase the risk of ischemia in the important organs and is helpful to control the fluid resuscitation.