Non-Adrenergic Vasopressors in Patients with or at Risk for Vasodilatory Shock. A Systematic Review and Meta-Analysis of Randomized Trials
Non-Adrenergic Vasopressors in Patients with or at Risk for Vasodilatory Shock. A Systematic Review and Meta-Analysis of Randomized Trials
复制标题
DOI：
10.1371/journal.pone.0142605
复制
发表时间：
2015-11-11
期刊：
影响因子：
3.7
通讯作者：
Landoni, Giovanni
中科院分区：
文献类型：
--
作者：
Belletti, Alessandro;Musu, Mario;Landoni, Giovanni
简介 在几种危急情况下经常观察到低血压状态。如果没有及时恢复足够的平均动脉压，可能会出现组织灌注不足和器官功能障碍。液体和儿茶酚胺是危重低血压状态管理的基石。儿茶酚胺的副作用例如增加心肌耗氧量和发生心律失常是众所周知的。因此，近年来，人们对保留儿茶酚胺的药物如加压素、特利加压素和亚甲蓝的兴趣有所增加。然而，进行的随机试验很少，而且大多是小样本。因此，我们对随机试验进行了荟萃分析，以调查非儿茶酚胺能血管加压药对死亡率的影响。方法由两名独立研究者检索了 PubMed、BioMed Central 和 Embase（2014 年 12 月 31 日更新）。纳入标准为：随机分配治疗、至少一组接受非儿茶酚胺能血管升压药、患有血管舒张性休克或有血管舒张性休克风险的患者。排除标准是：交叉研究、儿科人群、非人类研究、仅作为摘要发表的研究、缺乏死亡率数据。研究的药物是加压素、特利加压素和亚甲蓝。主要终点是最长随访时的死亡率。结果我们的分析纳入了来自 20 项研究的总共 1,608 名患者。研究的背景包括脓毒症（10/20 研究 [50%]）、心脏手术（7/20 [35%]）、任何原因引起的血管舒张性休克（2/20 [19%]）和急性创伤性损伤（1/20 [5%]）。总体而言，汇总估计显示，非儿茶酚胺能药物治疗可提高生存率（278/810 [34.3%] vs 309/798 [38.7%]，风险比 = 0.88，95% 置信区间 = 0.79 至 0.98，p = 0.02）。独立分析时，没有一种药物与显着降低死亡率相关。在分析低偏倚风险的研究时，结果并未得到证实。结论 对于患有血管舒张性休克或有血管舒张性休克风险的患者，使用儿茶酚胺保留剂可能会提高生存率。需要对此主题进行进一步的研究来证实这一发现。
IntroductionHypotensive state is frequently observed in several critical conditions. If an adequate mean arterial pressure is not promptly restored, insufficient tissue perfusion and organ dysfunction may develop. Fluids and catecholamines are the cornerstone of critical hypotensive states management. Catecholamines side effects such as increased myocardial oxygen consumption and development of arrhythmias are well known. Thus, in recent years, interest in catecholamine-sparing agents such as vasopressin, terlipressin and methylene blue has increased; however, few randomized trials, mostly with small sample sizes, have been performed. We therefore conducted a meta-analysis of randomized trials to investigate the effect of non-catecholaminergic vasopressors on mortality.MethodsPubMed, BioMed Central and Embase were searched (update December 31st, 2014) by two independent investigators. Inclusion criteria were: random allocation to treatment, at least one group receiving a non-catecholaminergic vasopressor, patients with or at risk for vasodilatory shock. Exclusion criteria were: crossover studies, pediatric population, nonhuman studies, studies published as abstract only, lack of data on mortality. Studied drugs were vasopressin, terlipressin and methylene blue. Primary endpoint was mortality at the longest follow-up available.ResultsA total of 1,608 patients from 20 studies were included in our analysis. The studied settings were sepsis (10/20 studies [50%]), cardiac surgery (7/20 [35%]), vasodilatory shock due to any cause (2/20 [19%]), and acute traumatic injury (1/20 [5%]). Overall, pooled estimates showed that treatment with non-catecholaminergic agents improves survival (278/810 [34.3%] versus 309/798 [38.7%], risk ratio = 0.88, 95% confidence interval = 0.79 to 0.98, p = 0.02). None of the drugs was associated with significant reduction inmortality when analyzed independently. Results were not confirmed when analyzing studies with a low risk of bias.ConclusionsCatecholamine-sparing agents in patients with or at risk for vasodilatory shock may improve survival. Further researches on this topic are needed to confirm the finding.