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医汇心血管学术 > 多巴胺 - 无形的杀手?

多巴胺 - 无形的杀手?

发表于 2014-10-09 14:39:49
最近的病例讨论中,我们反复提到多巴胺的使用是否合理。我过去也谈到,多巴胺在外科领域,已经没有什么使用价值。从个人的经验看,多巴胺的作用太广泛但不清楚,在提高后负荷时,对心肌刺激较大,心律失常太多,心肌氧耗增大。我个人是主张分别选用/合用,分别调节作用单一的药物。 从理论上看,在休克治疗中,去甲已经被证明效果优于多巴胺。在心衰方面,文献中很多关于多巴胺导致更坏结果的报告。至于最为得意的肾保护,也被证明是不存在的(Lancet. 2000 Dec 23-30;356(9248):2139-43)。就大家经常遇到的休克而言,最近一篇文章,对欧洲 98 个ICU中,3,147名感染性和非感染性病人分析,表明用多巴胺者,ICU 死亡率,30天死亡率和住院死亡率,都比不用多巴胺高(见表)。Does dopamine administration in shock influence outcome? Results of the Sepsis Occurrence in Acutely Ill Patients (SOAP) Study.Sakr Y, Reinhart K, Vincent JL, Sprung CL, Moreno R, Ranieri VM, De Backer D, Payen D.Department of Intensive Care, Erasme Hospital, Free University of Brussels, Belgium.Crit Care Med. 2006 Mar;34(3):589-97.OBJECTIVE: The optimal adrenergic support in shock is controversial. We investigated whether dopamine administration influences the outcome from shock. DESIGN: Cohort, multiple-center, observational study. SETTING: One hundred and ninety-eight European intensive care units. PATIENTS: All adult patients admitted to a participating intensive care unit between May 1 and May 15, 2002. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patients were followed up until death, until hospital discharge, or for 60 days. Shock was defined as hemodynamic compromise necessitating the administration of vasopressor catecholamines. Of 3,147 patients, 1,058 (33.6%) had shock at any time; 462 (14.7%) had septic shock. The intensive care unit mortality rate for shock was 38.3% and 47.4% for septic shock. Of patients in shock, 375 (35.4%) received dopamine (dopamine group) and 683 (64.6%) never received dopamine. Age, gender, Simplified Acute Physiology Score II, and Sequential Organ Failure Assessment score were comparable between the two groups. The dopamine group had higher intensive care unit (42.9% vs. 35.7%, p=.02) and hospital (49.9% vs. 41.7%, p=.01) mortality rates. A Kaplan-Meier survival curve showed diminished 30 day-survival in the dopamine group (log rank=4.6, p=.032). In a multivariate analysis with intensive care unit outcome as the dependent factor, age, cancer, medical admissions, higher mean Sequential Organ Failure Assessment score, higher mean fluid balance, and dopamine administration were independent risk factors for intensive care unit mortality in patients with shock. CONCLUSIONS: This observational study suggests that dopamine administration may be associated with increased mortality rates in shock. There is a need for a prospective study comparing dopamine with other catecholamines in the management of circulatory shock.同期的 Critical Care Medicine 中的编者按指出,大家好像对多巴胺的偏爱好像是社区医院的传统和对去甲的“惧怕”,并没有什么依据。“一点β ,一点 ɑ ,兴许管用”。(也就是我的万金油之说)。There is no rational evidence to support this, but one may argue that among community hospital physicians, there is a certain “fear” of norepinephrine and the belief that dopamine, “a little bit β and a little bit ɑ, as inotrope or vasopressor, may do the job.”同时,该编者按再次强调了多巴胺对肾没有保护作用,反而增加肾氧耗。There is evidence that dopamine may increase renal oxygen consumption and may therefore jeopardize renal oxygen supply/demand balance. There is also ample evidence that the so-called renal dopamine does not change mortality, risk of renal failure, or need for extracorporeal renal replacement therapy ([24]). The evidence-based guidelines published in 2004 in this journal do not support the use of dopamine as renal protection or renal salvage agent ([27]).随后一篇由危重医学高手 Pinsky 共同作者的读书会中,指出一个尖锐的问题:多巴胺是不是无形的杀手?Could dopamine be a silent killer? (http://ccforum.com.foyer.swmed.edu/content/11/1/302#B11)他们分析了以上研究的长处和不足,并指出去甲早已被证明比多巴胺治疗低血压有效,并说明正在进行的多巴胺和去甲治疗休克的临床试验(http://www.clinicaltrials.gov/ct/show/NCT00314704)。 虽然这一研究有其局限性,但至少说明,多巴胺已经不是什么万应药。之所以有人提出疑问,进行对比研究,正是表明其副作用正在被人们注意。我已经十多年没有在主流外科麻醉和危重医学领域见到多巴胺了。 希望大家提高警惕。 来源:丁香园
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