Association of Vasopressor Choice with Clinical and Functional Outcomes Following Moderate to Severe Traumatic Brain Injury: A TRACK-TBI Study.
Association of Vasopressor Choice with Clinical and Functional Outcomes Following Moderate to Severe Traumatic Brain Injury: A TRACK-TBI Study.
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DOI：
10.1007/s12028-021-01280-7
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发表时间：
2022-02
影响因子：
3.5
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中科院分区：
文献类型：
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中重度创伤性脑损伤（TBI）后早期低血压与死亡率增加和长期预后不良相关。目前的指南建议使用静脉血管加压药来支持TBI后的血压;然而，指南没有指定血管加压药类型，导致临床实践的变化。只有很少的数据可用于指导临床医生选择最佳的早期血管加压药，以支持TBI后的血压。因此，我们进行了一项多中心研究，以检查TBI后支持血压的初始血管加压药选择及其与损伤后临床和功能结局的相关性。我们对参加TRACK-TBI研究的患者进行了回顾性队列研究，TRACK-TBI研究是一项在参与的1级创伤中心评估的TBI患者的18中心前瞻性队列研究。我们检查了患有中重度TBI（定义为格拉斯哥昏迷量表评分<13）的成年人，他们被送入ICU并在入院后48小时内接受静脉血管加压剂治疗。主要暴露是初始血管加压药选择（苯肾上腺素与去甲肾上腺素），主要结局是6个月格拉斯哥结局量表扩展（GOSE），次要结局包括：住院时间、ICU住院时间、住院死亡率、新透析要求和6个月残疾评定量表（DRS）。使用回归分析评估暴露于去甲肾上腺素与苯肾上腺素的患者之间的结局差异，并使用倾向加权来解决治疗组非随机分配和受试者脱落导致的选择偏倚。最终研究样本包括156名患者，其中79名（51%）接受去甲肾上腺素，69名（44%）接受苯肾上腺素，8名（5%）接受替代药物作为初始血管加压药。121例（77%）患者为男性，平均年龄为43.1岁。在接受去甲肾上腺素作为初始血管加压剂的患者中，32%的患者结局良好（GOSE 5-8），而接受苯肾上腺素作为初始血管加压剂的患者中，40%的患者结局良好。与苯肾上腺素相比，去甲肾上腺素暴露与6个月GOSE改善（加权比值比1.40，95% CI 0.66-2.96，p=0.37）或任何次要结局无显著相关性。大多数中重度TBI患者接受苯肾上腺素或去甲肾上腺素作为脑损伤后血压支持的一线药物。与苯肾上腺素相比，最初选择去甲肾上腺素与临床或功能结局改善无关。
Early hypotension following moderate-severe traumatic brain injury (TBI) is associated with increased mortality and poor long-term outcomes. Current guidelines suggest the use of intravenous vasopressors to support blood pressure following TBI; however, guidelines do not specify vasopressor type, resulting in variation in clinical practice. Minimal data are available to guide clinicians on optimal early vasopressor choice to support blood pressure following TBI. Therefore, we conducted a multicenter study to examine initial vasopressor choice for the support of blood pressure following TBI and its association with clinical and functional outcomes after injury. We conducted a retrospective cohort study of patients enrolled in the TRACK-TBI study, an 18-center prospective cohort study of TBI patients evaluated in participating Level 1 trauma centers. We examined adults with moderate-severe TBI (defined as Glasgow Coma Scale score <13) who were admitted to the ICU and received an intravenous vasopressor within 48 hours of admission. The primary exposure was initial vasopressor choice (phenylephrine versus norepinephrine) and the primary outcome was 6-month Glasgow Outcomes Scale Extended (GOSE), with the following secondary outcomes: length of hospital stay, length of ICU stay, in-hospital mortality, new requirement for dialysis, and 6-month Disability Rating Scale (DRS). Regression analysis was used to assess differences in outcomes between patients exposed to norepinephrine versus phenylephrine, with propensity-weighting to address selection bias due to both the non-random allocation of the treatment groups and subject drop-out. The final study sample included 156 patients, of whom 79 (51%) received norepinephrine, 69 (44%) received phenylephrine, and 8 (5%) received an alternate drug as their initial vasopressor. 121 (77%) of patients were male, with a mean age of 43.1 years. Of patients receiving norepinephrine as their initial vasopressor, 32% had a favorable outcome (GOSE 5-8), while 40% of patients receiving phenylephrine as their initial vasopressor had a favorable outcome. Compared to phenylephrine, exposure to norepinephrine was not significantly associated with improved 6-month GOSE (weighted odds ratio 1.40, 95% CI 0.66-2.96, p=0.37) or any secondary outcome. The majority of patients with moderate-severe TBI received either phenylephrine or norepinephrine as first-line agents for blood pressure support following brain injury. Initial choice of norepinephrine, compared to phenylephrine, was not associated with improved clinical or functional outcomes.
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