Georg Franz Lehner, Timo Mayerhöfer, Fabian Perschinka, Bernhard Benda, Michael Joannidis
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引用次数: 0
Abstract
Hemodynamic stabilization and preservation of organ perfusion are central elements in the management of septic shock. This is achieved by fluid resuscitation and by administration of vasoactive agents. Current guidelines recommend norepinephrine as the first-line vasoactive substance. In cases of high norepinephrine requirements the addition of nonadrenergic vasopressors is recommended. Furthermore, evidence suggests that early use of complementary vasoactive substances may provide additional benefits. Such a regimen, in terms of a broad-spectrum vasopressor approach, appears physiologically plausible. Post hoc analyses of studies investigating vasopressin or angiotensin II also suggest that specific subphenotypes may particularly benefit from individual vasoactive agents. Adjunctive therapy with hydrocortisone and fludrocortisone can improve vasopressor responsiveness and reduce mortality. In cases of cardiac dysfunction, a trial with dobutamine or a switch from norepinephrine to epinephrine is recommended. To enhance inodilator effects, milrinone or levosimendan may represent additional therapeutic options for certain patients. Although short-acting beta-blockers are not part of the standard treatment for septic shock, they may, in selected cases, contribute to hemodynamic improvement in patients with inadequately high sinus tachycardia or atrial tachyarrhythmias. Based on pathophysiological considerations and the currently available evidence, targeted use of specific vasoactive substances in defined subphenotypes may be justified. An initial broad-spectrum vasopressor strategy incorporating biomarkers such as renin and patient-specific characteristics followed by a focused de-escalation approach could represent a promising concept. However, the effectiveness of these strategies requires further investigation in randomized controlled trials.
期刊介绍:
Medizinische Klinik – Intensivmedizin und Notfallmedizin is an internationally respected interdisciplinary journal. It is intended for physicians, nurses, respiratory and physical therapists active in intensive care and accident/emergency units, but also for internists, anesthesiologists, surgeons, neurologists, and pediatricians with special interest in intensive care medicine.
Comprehensive reviews describe the most recent advances in the field of internal medicine with special focus on intensive care problems. Freely submitted original articles present important studies in this discipline and promote scientific exchange, while articles in the category Photo essay feature interesting cases and aim at optimizing diagnostic and therapeutic strategies. In the rubric journal club well-respected experts comment on outstanding international publications. Review articles under the rubric "Continuing Medical Education" present verified results of scientific research and their integration into daily practice. The rubrics "Nursing practice" and "Physical therapy" round out the information.