Early Vasopressor Utilization Strategies and Outcomes in Critically Ill Patients With Severe Traumatic Brain Injury.
Early Vasopressor Utilization Strategies and Outcomes in Critically Ill Patients With Severe Traumatic Brain Injury.
复制标题
严重创伤性脑损伤危重患者的早期血管加压药利用策略和结果。
DOI：
10.1213/ane.0000000000005949
复制
发表时间：
2022-12-01
影响因子：
5.7
通讯作者：
中科院分区：
文献类型：
--
作者：
严重创伤性脑损伤（sTBI）后的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升压药（通常是去甲肾上腺素和去氧肾上腺素）来支持 TBI 后的血压。然而，指南没有具体说明升压药的类型，导致临床实践存在差异。我们描述了 TBI 危重患者的早期升压药使用模式，并检查了去甲肾上腺素（与去氧肾上腺素）的使用与 sTBI 后医院死亡率之间的关联。我们对 2009 年至 2018 年间参与 Premier Healthcare 数据库的美国医院进行了回顾性队列研究。我们检查了初步诊断为 sTBI 的成年患者（>17 岁），他们在受伤后在重症监护室 (ICU) 接受护理。主要暴露是入院前两天内血管加压药的选择（去氧肾上腺素与去甲肾上腺素）。主要结局是院内死亡率。检查的次要结局包括住院时间 (LOS) 和重症监护室 LOS。我们对所有放置 ICP 监测仪的患者进行了事后亚组分析。使用回归分析来评估暴露于去氧肾上腺素和去甲肾上腺素的患者之间的结果差异，并通过倾向匹配来解决由于治疗组的非随机分配而导致的选择偏差。从 2009 年到 2018 年，66,610 名 sTBI 患者中有 24,718 名（37.1%）在住院的前两天内接受了血管加压药。在这些患者中，60.6% (n=14991) 仅接受去氧肾上腺素治疗，10.8% (n=2668) 仅接受去甲肾上腺素治疗，3.5% (n=877) 接受其他血管加压药治疗，25.0% (n=6182) 接受多种血管加压药治疗。在此期间，sTBI 后所有血管加压药的使用都有所增加。不同医院水平的升压药选择存在中等程度的差异（23.1%）。在倾向匹配分析中，与去氧肾上腺素相比，使用去甲肾上腺素与院内死亡风险增加相关（OR 1.65，CI 1.46-1.86，p <0.0001）。患有 sTBI 的危重患者早期使用血管加压药很常见，并且在过去十年中有所增加，并且在治疗 TBI 患者的医院之间存在差异。在倾向匹配分析中，与去氧肾上腺素相比，去甲肾上腺素与院内死亡风险增加相关。鉴于血管加压药的使用存在很大差异以及疗效可能存在差异，我们的分析表明需要进行随机对照试验，以便更好地为 sTBI 患者选择血管加压药提供信息。
Early hypotension following severe traumatic brain injury (sTBI) is associated with increased mortality and poor long-term outcomes. Current guidelines suggest the use of intravenous vasopressors, commonly norepinephrine and phenylephrine, to support blood pressure following TBI. However, guidelines do not specify vasopressor type, resulting in variation in clinical practice. We describe early vasopressor utilization patterns in critically ill patients with TBI and examine the association between utilization of norepinephrine, compared to phenylephrine, with hospital mortality following sTBI. We conducted a retrospective cohort study of United States hospitals participating in the Premier Healthcare Database between 2009–2018. We examined adult patients (>17 years) with a primary diagnosis of sTBI who received care in an intensive care unit (ICU) following injury. The primary exposure was vasopressor choice (phenylephrine versus norepinephrine) within the first two days of hospital admission. The primary outcome was in-hospital mortality. Secondary outcomes examined included hospital length of stay (LOS) and intensive care unit LOS. We conducted a post-hoc subgroup analysis in all patients with ICP monitor placement. Regression analysis was used to assess differences in outcomes between patients exposed to phenylephrine versus norepinephrine, with propensity-matching to address selection bias due to the non-random allocation of treatment groups. From 2009–2018, 24,718 (37.1%) of 66,610 sTBI patients received vasopressors within the first two days of hospitalization. Among these patients, 60.6% (n=14991) received only phenylephrine, 10.8% (n=2668) received only norepinephrine, 3.5% (n=877) received other vasopressors, and 25.0% (n=6182) received multiple vasopressors. In that time period, use of all vasopressors following sTBI increased. A moderate degree of variation in vasopressor choice was explained at the individual hospital level (23.1%). In propensity-matched analysis, use of norepinephrine, compared to phenylephrine, was associated with an increased risk of in-hospital mortality (OR 1.65, CI 1.46–1.86, p <0.0001). Early vasopressor utilization among critically ill patients with sTBI is common, increasing over the last decade, and varies across hospitals caring for TBI patients. Norepinephrine, compared to phenylephrine, was associated with increased risk of in-hospital mortality in propensity-matched analysis. Given the wide variation in vasopressor utilization and possible differences in efficacy, our analysis suggests the need for randomized controlled trials to better inform vasopressor choice for patients with sTBI.