[Vasoactive agents in septic shock-individualized strategies].

IF 1.3 4区 医学 Q2 MEDICINE, GENERAL & INTERNAL
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.

感染性休克中的血管活性药物——个体化策略。
血流动力学的稳定和器官灌注的保存是处理感染性休克的核心要素。这是通过液体复苏和血管活性药物的管理来实现的。目前的指南推荐去甲肾上腺素作为一线血管活性物质。在高去甲肾上腺素需求的情况下,建议添加非肾上腺素能性血管加压药。此外,有证据表明,早期使用补充血管活性物质可能提供额外的好处。从广谱血管加压药物的角度来看,这种治疗方案在生理学上似乎是合理的。对血管加压素或血管紧张素II研究的事后分析也表明,特定的亚表型可能特别受益于单个血管活性药物。氢化可的松和氟化可的松辅助治疗可改善血管加压反应性,降低死亡率。在心功能不全的情况下,建议使用多巴酚丁胺或从去甲肾上腺素切换到肾上腺素。为了增强调节作用,米立酮或左西孟旦可能是某些患者的额外治疗选择。虽然短效β受体阻滞剂不是感染性休克标准治疗的一部分,但在某些情况下,它们可能有助于改善不充分高窦性心动过速或房性心动过速患者的血流动力学。基于病理生理学的考虑和目前可用的证据,针对特定亚表型的特定血管活性物质的靶向使用可能是合理的。最初的广谱血管加压策略结合肾素等生物标志物和患者特异性特征,然后集中降压方法可能代表一个有前途的概念。然而,这些策略的有效性需要在随机对照试验中进一步研究。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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来源期刊
CiteScore
2.60
自引率
9.10%
发文量
93
审稿时长
6-12 weeks
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.
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