Daniel De Backer, Rocio Rimachi, Jacques Duranteau
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Inotropes can also be used in selected conditions. At the de-escalation phase, fluid withdrawal should be considered. Safe fluid withdrawal may be achieved when applied in selected patients with preserved tissue perfusion presenting signs of fluid intolerance. When applied, stopping rules should be set. Dobutamine, milrinone and levosimendan increase renal perfusion in AKI associated with cardiac failure or after cardiac surgery. However, the impact of these agents in sepsis is not well defined. Regarding vasopressors, norepinephrine is the first-line vasopressor agent, but vasopressin derivative may limit the requirement of renal replacement therapy. Angiotensin has promising effects in a limited size post-Hoc analysis of a RCT, but these data need to be confirmed. While correction of severe hypotension is associated with improved renal perfusion and function, the optimal mean arterial pressure (MAP) target level remains undefined, Systematic increase in MAP results in variable changes in renal perfusion. It sounds reasonable to individualize MAP target, paying attention to central venous and intraabdominal pressures, as well as to the response to an increase in MAP.</p><p><strong>Summary: </strong>Recent studies have refined the impact of the various hemodynamic interventions on renal perfusion and function in critically ill patients with AKI. 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引用次数: 0
摘要
综述的目的:讨论血液动力学管理在急性肾损伤重症患者中的作用:急性肾损伤(AKI)可能与肾脏灌注的持续改变有关,即使在心输出量和血压保持不变的情况下也是如此。通过肾脏多普勒或造影剂增强超声波可对旨在增加肾脏灌注的干预措施的效果进行最佳评估。然而,利用这些技术获得的数据有限,大部分文献都是基于肾功能的替代指标,如使用肾脏替代疗法的发生率。输液可增加肾脏灌注,但其效果难以预测,且与对心排血量和动脉压的影响无关。在某些情况下也可以使用肌注药物。在降级阶段,应考虑撤液。如果选定的患者组织灌注得到保留,并出现液体不耐受的迹象,则可安全撤液。使用时应制定停止规则。多巴酚丁胺、米力农和左西孟旦可增加与心力衰竭相关的 AKI 或心脏手术后的肾脏灌注。然而,这些药物对脓毒症的影响尚不明确。关于血管加压药,去甲肾上腺素是一线血管加压药,但血管加压素衍生物可能会限制肾脏替代疗法的需求。在一项规模有限的 RCT 事后分析中,血管紧张素具有良好的效果,但这些数据尚需证实。虽然纠正严重低血压与改善肾脏灌注和功能有关,但最佳平均动脉压(MAP)目标水平仍未确定。根据中心静脉压和腹腔内压以及对 MAP 升高的反应来确定 MAP 目标值是合理的:最近的研究已经完善了各种血流动力学干预措施对 AKI 重症患者肾脏灌注和功能的影响。虽然其中一些干预措施能改善肾脏灌注,但它们对肾功能的影响却不尽相同。
Purpose of review: To discuss the role of hemodynamic management in critically ill patients with acute kidney injury.
Recent findings: Acute kidney injury (AKI) may be associated with persistent alterations in renal perfusion, even when cardiac output and blood pressure are preserved. The effects of interventions aiming at increasing renal perfusion are best evaluated by renal Doppler or contrast enhance ultrasound. However, limited data have been acquired with these techniques and the essential of the literature is based on surrogates of renal function such as incidence of use of renal replacement therapy. Fluids may increase renal perfusion but their effects are quite unpredictable and can be dissociated from their impact on cardiac output and arterial pressure. Inotropes can also be used in selected conditions. At the de-escalation phase, fluid withdrawal should be considered. Safe fluid withdrawal may be achieved when applied in selected patients with preserved tissue perfusion presenting signs of fluid intolerance. When applied, stopping rules should be set. Dobutamine, milrinone and levosimendan increase renal perfusion in AKI associated with cardiac failure or after cardiac surgery. However, the impact of these agents in sepsis is not well defined. Regarding vasopressors, norepinephrine is the first-line vasopressor agent, but vasopressin derivative may limit the requirement of renal replacement therapy. Angiotensin has promising effects in a limited size post-Hoc analysis of a RCT, but these data need to be confirmed. While correction of severe hypotension is associated with improved renal perfusion and function, the optimal mean arterial pressure (MAP) target level remains undefined, Systematic increase in MAP results in variable changes in renal perfusion. It sounds reasonable to individualize MAP target, paying attention to central venous and intraabdominal pressures, as well as to the response to an increase in MAP.
Summary: Recent studies have refined the impact of the various hemodynamic interventions on renal perfusion and function in critically ill patients with AKI. Though several of these interventions improve renal perfusion, their impact on renal function is more variable.
期刊介绍:
Current Opinion in Critical Care delivers a broad-based perspective on the most recent and most exciting developments in critical care from across the world. Published bimonthly and featuring thirteen key topics – including the respiratory system, neuroscience, trauma and infectious diseases – the journal’s renowned team of guest editors ensure a balanced, expert assessment of the recently published literature in each respective field with insightful editorials and on-the-mark invited reviews.