Effects of dopamine and epinephrine infusions on renal hemodynamics in severe malaria and severe sepsis
Effects of dopamine and epinephrine infusions on renal hemodynamics in severe malaria and severe sepsis
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DOI：
10.1097/00003246-200005000-00016
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发表时间：
2000-05-01
影响因子：
8.8
通讯作者：
White, NJ
中科院分区：
文献类型：
--
作者：
Day, NPJ;Phu, NH;White, NJ
目的：描述和比较不同剂量多巴胺和肾上腺素对重症疟疾和严重脓毒症患者肾脏血流动力学和氧转运的影响。设计：前瞻性、对照、交叉试验。环境：越南一家传染病医院的重症监护室。患者：严重恶性疟疾14例，严重败血症5例。干预措施：在开放的交叉设计中，我们观察了肾上腺素和多巴胺分步输注对肾脏和全身血流动力学和氧转运的影响。我们使用透视引导导管，用热稀释法测量肾血流量和心输出量。根据肾血浆流量和肾动静脉血浆肌酐差值计算各时间点肌酐清除率。测量和主要结果：多巴胺“肾”剂量（2.5 μ g/kg/min）与绝对肾血流量指数（RBFI）平均（95%置信区间）分数增加37%（13%至61%）和RBF与心输出量（RBF/CO）的分数增加35%（10%至59%；p = 0.007和p = 0.014分别）相关。肾脏供氧增加39%(14%至64%)(p = 0.002)，同时肾脏供氧率下降32%(20%至44%)(p = 0.003)，导致肾脏耗氧量无净变化。在较高剂量（10 μ g/kg/min）下，RBF和RBF/CO均与基线值无显著差异，并随着剂量的再次降低而进一步降低。这种迟滞没有明显的解释，在整个研究过程中肾脏耗氧量没有变化。由于发生乳酸酸中毒，19例患者中只有8例患者使用了肾上腺素，4例患者使用了全阶梯肾上腺素输注。肾上腺素输注与肾血管阻力的显著增加（p = 0.0003和0.0003）相关，无论从绝对值还是与多巴胺相比。RBF/CO降低（p = 0.002, p = 0.005）。2003)，肾氧提取比代偿性增加（p = 0.005, p = 0.05）。0001)， RBFI和肾脏耗氧量在整个肾上腺素输注过程中保持不变。肾上腺素和多巴胺均未显著影响肌酐清除率或尿量。在研究时，12名患者（63%）已确定肾功能衰竭（血浆肌酐，bb0.3 mg/dl），尽管肾功能衰竭的存在或不存在并未显著影响研究药物的效果。然而，总体而言，肾功能衰竭的存在与较低的平均肾耗氧量、较低的平均肾耗氧量占全身耗氧量的比例以及较高的平均肾血管阻力有关。结论：尽管多巴胺增加，肾上腺素减少肾血流量，但没有证据表明在任何剂量下，这两种药物对肾脏氧代谢或功能产生有益或有害的影响。
Objective: To describe and compare the effects of dopamine and epinephrine in various doses on renal hemodynamics and oxygen transport in patients with severe malaria and severe sepsis.Design: Prospective, controlled, crossover trial.Setting: The intensive care unit of an infectious diseases hospital in Viet Nam.Patients: Fourteen patients with severe falciparum malaria and five with severe sepsis.Interventions: In an open, crossover design, we observed the effects on renal and systemic hemodynamics and oxygen transport of separate stepped Infusions of epinephrine and dopamine. We measured renal blood flow (RBF) and cardiac output by the thermodilution method using fluoroscopically guided catheters. Creatinine clearance at each time point was calculated from the renal plasma flow and the renal arteriovenous difference in plasma creatinine.Measurements and Main Results: Dopamine at a "renal" dose (2.5 mu g/kg/min) was associated with a mean (95% confidence interval) fractional increase in the absolute renal blood flow index (RBFI) of 37% (13% to 61%) and in RBF as a fraction of cardiac output (RBF/CO) of 35% (10% to 59%; p = .007 and p = .014, respectively). The consequent 39% (14% to 64%) increase in renal oxygen supply (p = .002) was accompanied by a 32% (20% to 44%) decrease in the renal oxygen extraction ratio (p = .0003), leading to no net change in renal oxygen consumption. At higher doses (10 mu g/kg/min), both RBF and RBF/CO were not significantly different from baseline values and decreased further as the dose was reduced again. There was no obvious explanation for this hysteresis, There was no change in renal oxygen consumption throughout the study. Because lactic acidosis developed, epinephrine was only given to eight of the 19 patients, and the full stepped epinephrine infusion was given to four patients. Epinephrine infusion was associated, both in absolute terms and when compared with dopamine, with a significant increase in renal vascular resistance (p = .0003 and .0005, respectively), a decrease in RBF/CO (p = .002 and .03), and a compensatory increase in the renal oxygen extraction ratio (p = .005 and .0001), RBFI and renal oxygen consumption remained constant throughout the epinephrine infusion profile. Neither epinephrine nor dopamine significantly affected creatinine clearance or urine output. Twelve patients (63%) were in established renal failure (plasma creatinine, >3 mg/dl) at the time of the study, although the presence or absence of renal failure did not significantly influence the effects of the study drugs. However, overall, the presence of renal failure was associated with a lower mean renal oxygen consumption, a lower mean renal oxygen consumption as a fraction of systemic oxygen consumption, and a higher mean renal vascular resistance.Conclusion: Although dopamine increased and epinephrine decreased fractional renal blood flow, there was no evidence that either drug produced either a beneficial or a deleterious effect on renal oxygen metabolism or function at any of the doses investigated.