Báo cáo y học: Choice of vasopressor in septic shock: does it matter

Tuyển tập các báo cáo nghiên cứu về y học được đăng trên tạp chí y học Critical Care giúp cho các bạn có thêm kiến thức về ngành y học đề tài: Choice of vasopressor in septic shock: does it matter?
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Báo cáo y học: "Choice of vasopressor in septic shock: does it matter" Available online http://ccforum.com/content/11/6/174CommentaryChoice of vasopressor in septic shock: does it matter?Gourang P Patel and Robert A BalkRush Medical College, Rush University Medical Center, 1753 West Congress Parkway, Chicago, Illinois 60612, USACorresponding author: Robert A Balk, rbalk@rush.eduPublished: 6 November 2007 Critical Care 2007, 11:174 (doi:10.1186/cc6159)This article is online at http://ccforum.com/content/11/6/174© 2007 BioMed Central LtdAbstract In an attempt to determine the optimum vasopressor to use in the management of patients with septic shock, Annane andSeptic shock is a medical emergency that is associated with coworkers conducted a multicenter, prospective, randomized,mortality rates of 40-70%. Prompt recognition and institution of double-blind, controlled clinical trial evaluating epinephrineeffective therapy is required for optimal outcome. When the shockstate persists after adequate fluid resuscitation, vasopressor versus norepinephrine (with dobutamine, if indicated) in thetherapy is required to improve and maintain adequate tissue/organ management of a well-defined adult population with septicperfusion in an attempt to improve survival and prevent the shock [1]. The trial involved patients from 19 intensive caredevelopment of multiple organ dysfunction and failure. Controversy units throughout France and was funded by the Frenchsurrounding the optimum choice of vasopressor strategy to utilize Ministry of Health. The study enrolled adults with well-definedin the management of patients with septic shock continues. A septic shock and evidence of organ dysfunction and/orrecent randomized study of epinephrine compared to nor-epinephrine (plus dobutamine when indicated) leads to more hypoperfusion. The primary outcome parameter was 28 dayquestions than answers. all-cause mortality. Despite finding a significantly higher arterial lactate level and lower pH during the first four days ofThe significant economic and mortality impact of severe therapy in the epinephrine treated patients, there was not asepsis and septic shock has often resulted in some significant difference in 28 day all-cause mortality or othercontroversy concerning optimum management strategies, important outcome parameters. Specifically, there was noparticularly in regard to choice of vasopressor support [1,2]. significant difference in discharge from the intensive care unitAnnane and colleagues have recently reported on the (ICU) or hospital, hemodynamic parameters, vasopressorevaluation of two vasopressor strategies in a multicenter trial withdrawal or organ dysfunction between the two treatmentof adult French septic shock patients [1]. The results of such strategies. Importantly, there was also no difference incontrolled clinical trials are valuable to clinicians since septic adverse events, such as arrhythmias or cardiac, neurologic, orshock has a reported mortality rate of 40-70% and currently ischemic events [1].there are no convincing data supporting the use of onevasopressor strategy over another [2]. Current consensus As we consider these intriguing results from the study byrecommendations from 11 different societies in the Surviving Annane and coworkers we are impressed by the intricacies ofSepsis Campaign guidelines recommend either dopamine or study design and acknowledge their use of an expandednorepinephrine as the initial vasopressor for patients with definition for early septic shock in the inclusion and exclusionseptic shock [3]. The 2004 practice parameter for criteria for study enrollment. The study was multi-centered,hemodynamic support of sepsis in adult patients from the randomized, with a double-blind treatment algorithm. TheSociety of Critical Care Medicine (SCCM) also recommends study participants were reasonably well randomized at thethe use of dopamine or norepinephrine as the initial start. The majority of infections were community acquired withvasopressor(s) to use in adults with septic shock [4]. the lung as the predominant site of infection. Given theDopamine was the traditional vasopressor choice for shock predominance of dopamine use in North America andmanagement, until recent reports of dopamine resistance Europe, we were surprised investigators chose to compareand/or its potential for tachyarrhythmias resulted in nor- epinephrine and norepinephrine [4-6]. A trial designepinephrine’s emergence as the preferred initial vasopressor comparing norepinephrine to dopamine, epinephrine, andin North America and Europe [4-6]. possibly vasopressin or phenylephrine would have had more ...