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你应该设置多低的限度?在脓毒症休克中平均动脉压的目标
原作者: Feras Khan, 江利冰翻译 肖锋 发布日期:2014-04-15

你应该设置多低的限度?在脓毒症休克中平均动脉压的目标
翻译:江利冰 校对:肖锋

Title: How low should you go? MAP Goals in Septic Shock
题目:你应该设置多低的限度?在脓毒症休克中平均动脉压的目标
Author 作者: Feras Khan

Background:
背景:
Since Rivers’ Early-Goal Directed Therapy, a MAP of 65 mm Hg was been the standard goal for blood pressure in septic shock
自从Rivers提出早期目标导向治疗后,平均动脉压65毫米汞柱就成为了脓毒症休克血压维持的标准目标值。
Some studies have suggested a higher target may be better for patients with hypertension
一些研究建议,如对高血压患者将平均动脉压维持在一个高一点的水平,可能预后效果更好。
Potentially less renal failure with a higher target
如果平均动脉压能够维持一个较高水平,可能会降低肾功能衰竭的发生率。
The Trial:
研究:
776 adult patients in France; Multi-center; randomized; non-blinded
776例法国成年患者;多中心;随机;非盲设计

All patients had septic shock and on vasopressors
所有的患者都患有脓毒症休克,并且已经使用血管升压药物。

MAP was maintained for 5 days or when the patient was weaned off pressors
平均动脉压维持5天,或者当患者可以脱离升压药物

Primary outcome: Mortality at Day 28
主要指标:28天死亡率

Low target 65-70 mm Hg vs high target 80-85 mm Hg
低目标65-70毫米汞柱和高目标80-85毫米汞柱

Outcome:
结果:
No significant difference in mortality at 28 days: 36.6%  (high target) vs 34% (low target) (95 %CI; 0.84 to 1.38; P=0.57)
28天死亡率没有显著的区别:36.6%( 高目标 ),34%(低目标)(95%的置信区间;0.84-1.38;P=0.57)。
No significant difference at 90 days: 43.8% (high target) vs 42.3% (low target) (95% CI; 0.83 to 1.30; P=0.74)
90天死亡率没有显著区别:43.8%(高目标),42.3%(低目标)(95%的置信区间;0.83-1.30;P=0.74)。
Incidence of newly diagnosed atrial fibrillation was higher in the high-target group
新诊断的心房颤动在高目标组发生率高。
Patients with chronic hypertension: those in the higher target group required less renal-replacement therapy
伴有慢性高血压的患者:在高目标组的这类患者较少需要肾脏替代治疗。
Significant percentage of patients in the high target group did not meet goal MAP BUT the trial mirrored actual clinical practice and allowed clinicians the ability to limit blood pressure and differences in actual MAP attained in both groups was significantly different
高目标组相当比例的患者没有达到目标平均动脉压,但是这个研究反应的是实际的临床操作,并且容许临床医师对血压进行控制,而且两组实际达到的血压之间的差异也是显著不同的。
Bottom Line:
要点:
A MAP goal of 65 is just fine in most patients
在大多数患者平均动脉压维持在65毫米汞柱是可以的。
Patients with chronic hypertension and atherosclerosis seem to benefit (less need for renal-replacement therapies) with a higher MAP: so aim higher in these patients or monitor renal function and increase MAP goals accordingly
平均动脉压维持在较高水平可能对伴有高血压以及动脉粥样硬化的患者有益(较少需要进行肾脏替代治疗):所以在这些患者中需要将平均动脉压维持在较高水平或者检测肾脏功能并相应增加平均动脉压的目标。
References 参考文献:
High versus Low Blood-Pressure Target in Patients with Septic Shock Pierre Asfar, M.D., Ph.D. et al. for the SEPSISPAM Investigators
March 18, 2014 DOI: 10.1056/NEJMoa1312173