Effects of norepinephrine on mean systemic pressure and venous return in human septic shock
Effects of norepinephrine on mean systemic pressure and venous return in human septic shock
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DOI：
10.1097/ccm.0b013e318260c6c3
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发表时间：
2012-12-01
影响因子：
8.8
通讯作者：
Monnet, Xavier
中科院分区：
文献类型：
--
作者：
Persichini, Romain;Silva, Serena;Monnet, Xavier
目的：去甲肾上腺素产生静脉收缩，可以增加平均全身压力和静脉回流阻力，但这尚未在人类感染性休克中进行研究。我们研究了这两种效应的相对重要性，以及当降低去甲肾上腺素剂量时对静脉回流的影响。设置：重症监护室。患者：16名感染性休克患者。测量：为了估计静脉回流曲线，我们构建了心脏指数（脉搏轮廓分析）和中心静脉压值对之间的回归线。这些值是在两个水平的呼气末正压下进行的15秒吸气末和呼气末阻塞期间测量的，目的是扩大心脏指数的范围：中心静脉压测量值和增加回归线的准确性。回归线的x轴截距用于估计平均体循环压力，回归线斜率的倒数用于量化静脉回流阻力。在降低去甲肾上腺素剂量之前和之后获得这些测量值。主要结果：将去甲肾上腺素的剂量从0.30（0.10-1.40）μ g/kg/min降低到0.19（0.08-1.15）μ g/kg/min，平均全身压从33 +/- 12 mm Hg降低到26 +/- 10 mm Hg（p = 0.0003）。多点心脏指数：中心静脉压关系的斜率增加（p = 0.02）。静脉回流阻力降低，即，1/斜率下降。同时，心脏指数从3.47 +/- 0.86 L/min/m2降至3.28 +/- 0.76 L/min/m2（p = 0.04），表明静脉回流减少。被动抬腿在更大程度上增加了心脏指数，（8% +/- 4%）比以前（1% +/- 4%）去甲肾上腺素减少（p = 0.001），表明在最低剂量的去甲肾上腺素下无应激血容量增加。在感染性休克患者中，减少去甲肾上腺素的剂量可降低平均全身压，静脉回流的阻力结果，静脉回流减少。(Crit Care Med 2012; 40：3146-3153）
Objectives: Norepinephrine exerts venoconstriction that could increase both the mean systemic pressure and the resistance to venous return, but this has not yet been investigated in human septic shock. We examined the relative importance of both effects and the resulting effect on venous return when decreasing the dose of norepinephrine.Setting: Intensive care unit.Patients: Sixteen septic shock patients.Measurements: For estimating the venous return curve, we constructed the regression line between the pairs of cardiac index (pulse contour analysis) and central venous pressure values. These values were measured during 15-sec end-inspiratory and end-expiratory ventilatory occlusions performed at two levels of positive end-expiratory pressure, in view of widening the range of cardiac index: central venous pressure measurements and increasing the accuracy of the regression line. The x-axis intercept of the regression line was used to estimate the mean systemic pressure and the inverse of the slope of the regression line to quantify resistance to venous return. These measurements were obtained before and after decreasing the dose of norepinephrine. Passive leg raising was performed before and after decreasing the dose of norepinephrine.Main Results: Decreasing the dose of norepinephrine from 0.30 (0.10-1.40) to 0.19 (0.08-1.15) mu g/kg/min decreased the mean systemic pressure from 33 +/- 12 mm Hg to 26 +/- 10 mm Hg (p = .0003). The slope of the multipoint cardiac index: central venous pressure relationship increased (p = .02). The resistance to venous return decreased, i.e., 1/slope decreased. Simultaneously, cardiac index decreased from 3.47 +/- 0.86 L/min/m(2) to 3.28 +/- 0.76 L/min/m(2) (p = .04), - indicating a decrease in venous return. Passive leg raising increased cardiac index to a larger extent after (8% +/- 4%) than before (1% +/- 4%) decreasing norepinephrine (p = .001), suggesting an increase in unstressed blood volume at the lowest dose of norepinephrine.Conclusions: In septic shock patients, decreasing the dose of norepinephrine decreased the mean systemic pressure and, to a lesser extent, the resistance to venous return. As a result, venous return decreased. (Crit Care Med 2012; 40:3146-3153)