脓毒症合并心衰患者容量复苏及血管活性药物治疗的研究进展

Progress in the treatment of sepsis with heart failure

脓毒症的容量复苏和血管活性药物的使用是非常重要的治疗环节,若脓毒症患者之前存在心力衰竭(HF)的情况,进行容量复苏和使用血管活性药物就要非常慎重;同时这种情况下的临床结局一般较差。总结了脓毒症合并HF患者的病理生理特点、复苏目标、血流动力学干预和辅助治疗措施(如正压通气和肾脏替代治疗)。脓毒症合并HF患者在复苏期间接受的液体虽然更少,但传统复苏目标并未增加风险,且可能改善预后。去甲肾上腺素仍是这类人群首选的血管加压药物,多巴胺可能诱发更多的心脏不良事件。应谨慎使用多巴酚丁胺,但与去甲肾上腺素合用时,适用于低心排血量的患者。如果血流动力学能够代偿,可继续使用β-受体阻滞剂。治疗过程中,必须仔细监测正压通气和肾脏替代治疗对心功能的影响。

Preexisting heart failure(HF)in patients with sepsis is associated with worse clinical outcomes.Core sepsis management includes aggressive volume resuscitation followed by vasopressors,however,large fluid boluses and vasoactive agents are concerning amid the cardiac dysfunction of HF.Evidence regarding the influence of HF on sepsis clinical outcomes,pathophysiologic concerns,resuscitation targets,hemodynamic interventions,and adjunct management(ie,positive pressure ventilatory support,and renal replacement therapy)in patients with sepsis and preexisting HF were summarized.Patients with sepsis and preexisting HF receive less fluid during resuscitation,however,evidence suggests traditional fluid resuscitation targets do not increase the risk of adverse events in HF patients with sepsis and likely improve outcomes.Norepinephrine remains the most well-supported vasopressor for patients with sepsis with preexisting HF,while dopamine may induce more cardiac adverse events.Dobutamine should be used cautiously given its generally detrimental effects but may have an application when combined with norepinephrine in patients with low cardiac output.β-blockers may be appropriate to continue in the absence of acute hemodynamic decompensation.Positive pressure ventilatory support and renal replacement must be carefully monitored for effects on cardiac function when HF is present.