重症监护病房的出院时间与随后的死亡率:一项前瞻性、多中心研究

John D. Santamaria, G. Duke, D. Pilcher, J. Moran, R. Bellomo
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引用次数: 41

摘要

心血管系统的一个重要功能是提供足够的全身血流量和灌注压,以实现和维持器官稳态。这一目标要求血管收缩剂和血管舒张剂的影响要谨慎平衡。然而,在“分布性休克”中,血管舒张状态占主导地位,可导致终末器官灌注不足。尽管满意甚至高心输出量,缺乏血管张力导致不可接受的,危险的低器官灌注。亚甲基蓝通常被临床医生用作各种医疗程序中的染料,或者较少用于治疗硝酸盐引起的高铁血红蛋白血症。重要的是,MB的血管收缩作用仅在一氧化氮(NO)上调的情况下表现出来。因此,在涉及非血管截瘫患者的简单手术中给予MB作为染料时,未见血压升高。一氧化氮结合并激活酶溶性鸟苷酸环化酶,形成环鸟苷单磷酸(cGMP),最终使血管平滑肌松弛。一氧化氮是由依赖钙的酶NO合成酶在低浓度下持续产生的。亚甲基蓝直接抑制NO合酶。它还抑制酶溶性鸟苷酸环化酶,防止cGMP的积累。通过竞争性地阻断NO的靶酶,MB降低了血管对cgmp依赖性血管扩张剂的反应性,并恢复血管张力。细胞内cGMP的增加使血管平滑肌和心肌细胞放松。这也许可以解释为什么实验动物研究表明,除了降低血管加压剂的需求外,给药MB后肌力支持也减少,这可能是由于缺血/再灌注损伤的减弱。虽然MB确实可以改善血压,但增强氧输送或降低MB继发死亡率尚未得到证实。鉴于这些不完整的数据,作者认为在获得更多信息之前,MB应该用于治疗对传统血管加压药物无反应的血管截瘫,而不是作为一线药物。显然,迫切需要大规模的随机对照试验来确定MB在治疗血管截瘫中的作用。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
The Timing of Discharge From the Intensive Care Unit and Subsequent Mortality: A Prospective, Multicenter Study
COMMENT An important function of the cardiovascular system is to provide adequate systemic blood flow and perfusion pressure to achieve and maintain organ homeostasis. This goal requires that vasoconstrictor and vasodilator influences be meticulously balanced. However, in “distributive shock,” a vasodilatory state predominates and can cause inadequate end-organ perfusion. Despite satisfactory or even high cardiac output, the lack of vascular tone results in unacceptable, dangerously low endorgan perfusion. Methylene blue is commonly used by clinicians as a dye in assorted medical procedures or, less frequently, to treat nitrateinduced methemoglobinemia. Importantly, the vasoconstrictive effect of MB is manifested only in circumstances of nitric oxide (NO) up-regulation. Hence, increases in blood pressure are not seen when MB is given as a dye during uncomplicated procedures involving nonvasoplegic patients. Nitric oxide binds to and activates the enzyme-soluble guanylate cyclase, forming cyclic guanosine monophosphate (cGMP), which, in turn, eventually produces vascular smooth muscle relaxation. Nitric oxide is continuously produced at low concentrations by the calcium-dependent enzyme NO synthase. Methylene blue directly inhibits NO synthase. It also inhibits the enzyme-soluble guanylate cyclase and prevents accumulation of cGMP. By competitively blocking the target enzyme of NO, MB reduces the responsiveness of vessels to cGMP-dependent vasodilators and restores vascular tone. Increases in intracellular cGMP relax both vascular smooth muscle and myocardial myocytes. This may explain why experimental animal studies have shown that, in addition to reduction in vasopressor requirements, inotropic support is reduced after administration of MB, probably owing to attenuation of ischemia/reperfusion injury. Although MB certainly improves blood pressure, enhanced oxygen delivery or reduced mortality secondary to MB has not yet been confirmed. Given these incomplete data, the authors believe that MB should be used to treat vasoplegia unresponsive to traditional vasopressors, rather than as a first-line agent, until more information becomes available. Clearly, large, randomized controlled trials are urgently required to establish the role of MB in treating vasoplegia.
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