感染性休克的循环功能支持-杜斌VIP免费

感染性休克的循环功能支持北京协和医院加强医疗科杜斌循环功能支持治疗—目的•维持血压以保证重要脏器的灌注和功能•保证足够的组织氧合液体复苏治疗•纠正低血容量–第一个24小时内输注晶体液10–20升或更多•液体的选择–等张溶液•乳酸林格氏液，生理盐水–胶体液•血液—血容量丢失超过30%•白蛋白—治疗晚期液体复苏治疗晶体液•价格低廉•增加血管内容量•增加血管外间隙–（外周水肿）晶体液•价格低廉•增加血管内容量•增加血管外间隙–（外周水肿）胶体液•急性复苏后•增加胶体渗透压•减少血管外间隙胶体液•急性复苏后•增加胶体渗透压•减少血管外间隙液体复苏治疗•临床病例血管活性药物•目的–用于容量复苏疗效不佳者，以维持或升高血压•适应证–充分的液体复苏•PAWP15–18mmHg–MAP<60mmHg血管活性药物•争论1：如何维持肾脏血流？–Isdopaminetherightanswer?血管活性药物—肾脏保护多巴胺vs多巴酚丁胺•前瞻性、随机、双盲研究•自身对照(n=23)•入选标准–Ccr>30ml/min–Cr<3.4mg/dl–UO>0.5ml/kg/hr血管活性药物—肾脏保护•分组（各5hr)–多巴胺200g/min–多巴酚丁胺175g/min–安慰剂5%GS•结果–pH，电解质，Cr和PAWP无差异血管活性药物—肾脏保护02468101214MAPCIPAWPPlaceboDobuDopa血管活性药物—肾脏保护020406080100120140160CcrUOFna%PlaceboDobuDopa血管活性药物—肾脏保护•多巴酚丁胺–改善肾脏灌注•多巴胺–仅具有利尿作用血管活性药物—肾脏保护多巴胺vs肾上腺素•动物试验•腹腔内感染模型•分组（各4hr）–Dopa2g/kg/min–Epi40g/min–Epi+Dopa血管活性药物—肾脏保护050100150060120180240MAPEpiDopaEpi+Dopa血管活性药物—肾脏保护-250255075100125060120180240-250255075100125060120180240-250255075100125060120180240多巴胺和肾上腺素对肾脏血管阻力的影响健康对照腹腔感染DOPADOPA+EpiEpi血管活性药物—肾脏保护-250255075100125060120180240-250255075100125060120180240多巴胺和肾上腺素对肾脏血管阻力的影响多巴胺肾上腺素多巴胺+肾上腺素健康对照腹腔感染血管活性药物—肾脏保护025507506012018002550750601201800255075060120180多巴胺和肾上腺素对肾脏血流的影响健康对照腹腔感染DOPADOPA+EpiEpi血管活性药物—肾脏保护025507506012018002550060120180健康对照腹腔感染多巴胺和肾上腺素对肾脏血流的影响多巴胺肾上腺素多巴胺+肾上腺素血管活性药物—肾脏保护102030405060baseline15min180minCcr(ml/min)健康对照-Epi感染-Epi健康对照-Epi+DA感染-Epi+DA血管活性药物—肾脏保护•肾上腺素组–肾血流明显增加–Ccr先降低，之后增加•多巴胺组•多巴胺＋肾上腺素组–肾血流和Ccr无明显增加血管活性药物—肾脏保护Question•Incriticallyillpatientswithoratriskforacuterenalfailure(ARF),doeslow-dosedopaminereduce–theincidenceorseverityofARF–mortality–ortheneedforhemodialysis?血管活性药物—肾脏保护•Datasources–Studiesinalllanguages–MEDLINEsearchfrom1966to1999•Studyselection–clinicaltrialsormeta-analysesevaluatinglow-dosedopamine(<5µg/kg/min)forthepreventionortreatmentofARFinhumans–reportingoutcomedataformortality,needfordialysis,ordevelopmentorworseningofARF血管活性药物—肾脏保护Mainresults•58studiesidentified•1oftheprimaryoutcomesreportedin24studies•17RCTs(854pts)includedintheanalysis血管活性药物—肾脏保护WeightedeventratesOutcomeRCTNo.ptsdopaminecontrolRRR(95%CI)PvalueMortality115084.9%5.6%14%(-66to56)0.69DevelopmentofARF1151117.9%19.5%20%(-14to44)0.50Needforhemodialysis1061816.2%16.5%10%(-21to34)0.86KellumJA,DeckerJM.Useofdopamineinacuterenalfailure:ameta-analysis.CritCareMed.2001Aug;29:1526-31血管活性药物—肾脏保护0.1110MortalityOnsetofARFNeedfordialysisKellumJA,DeckerJM.Useofdopamineinacuterenalfailure:ameta-analysis.CritCareMed.2001Aug;29:1526-31血管活性药物—肾脏保护•amulticenter,randomized,double...