減少加壓素暴露不能降低老年血管擴張性低血壓危重患者的90天死亡率
作者：
小柯機器人發布時間：2020/2/18 10:26:58
加拿大謝布克大學François Lamontagne研究團隊最近研究了減少加壓素暴露對老年血管擴張性低血壓危重患者90天死亡率的影響。相關論文2020年2月12日在線發表於國際頂尖學術期刊《美國醫學會雜誌》。
重症監護室（ICU）患者通常使用加壓素來升高血壓。平衡加壓素的風險和益處是一項挑戰，尤其對老年患者而言。
為了探討允許性低血壓是否能降低65歲及以上ICU患者90天內的死亡率，2017年7月至2019年3月，研究組在英國的65個ICU中進行了一項多中心、實用性、隨機、臨床試驗。
研究組招募了2600名65歲及以上伴有血管擴張性低血壓的患者，將其按1：1隨機分組，其中1291名接受允許性低血壓治療，即平均動脈壓目標為60-65mmHg；1307名接受常規治療。
最終有2463名患者被納入主要結果分析。允許性低血壓組的患者使用加壓素的中位持續時間為33小時，顯著短於常規治療組（38小時）。允許性低血壓組患者的90天死亡率為41.0%，而常規治療組為43.8%，校正後的比值比為0.82。
允許性低血壓組有79名患者（6.2%）發生嚴重不良事件，包括41例急性腎功能衰竭和12例室上性心律失常；常規治療組有75名（5.8%），包括33例急性腎功能衰竭和12例室上性心律失常。
總之，對於65歲及以上接受加壓藥來治療血管擴張性低血壓的老年患者，允許性低血壓與常規治療相比，並不能顯著降低90天內的死亡率。
附：英文原文
Title: Effect of Reduced Exposure to Vasopressors on 90-Day Mortality in Older Critically Ill Patients With Vasodilatory Hypotension: A Randomized Clinical Trial
Author: Franois Lamontagne, Alvin Richards-Belle, Karen Thomas, David A. Harrison, M. Zia Sadique, Richard D. Grieve, Julie Camsooksai, Robert Darnell, Anthony C. Gordon, Doreen Henry, Nicholas Hudson, Alexina J. Mason, Michelle Saull, Chris Whitman, J. Duncan Young, Kathryn M. Rowan, Paul R. Mouncey
Issue&Volume: February 12, 2020
Abstract:
Importance Vasopressors are commonly administered to intensive care unit (ICU) patients to raise blood pressure. Balancing risks and benefits of vasopressors is a challenge, particularly in older patients.
Objective To determine whether reducing exposure to vasopressors through permissive hypotension (mean arterial pressure [MAP] target, 60-65 mm Hg) reduces mortality at 90 days in ICU patients aged 65 years or older with vasodilatory hypotension.
Design, Setting, and Participants A multicenter, pragmatic, randomized clinical trial was conducted in 65 ICUs in the United Kingdom and included 2600 randomized patients aged 65 years or older with vasodilatory hypotension (assessed by treating clinician). The study was conducted from July 2017 to March 2019, and follow-up was completed in August 2019.
Interventions Patients were randomized 1:1 to vasopressors guided either by MAP target (60-65 mm Hg, permissive hypotension) (n=1291) or according to usual care (at the discretion of treating clinicians) (n=1307).
Main Outcome and Measures The primary clinical outcome was all-cause mortality at 90 days.
Results Of 2600 randomized patients, after removal of those who declined or had withdrawn consent, 2463 (95%) were included in the analysis of the primary outcome (mean [SD] age 75 years [7 years]; 1387 [57%] men). Patients randomized to the permissive hypotension group had lower exposure to vasopressors compared with those in the usual care group (median duration 33 hours vs 38 hours; difference in medians, –5.0; 95% CI, –7.8 to –2.2 hours; total dose in norepinephrine equivalents median, 17.7 mg vs 26.4 mg; difference in medians, –8.7 mg; 95% CI, –12.8 to 4.6 mg). At 90 days, 500 of 1221 (41.0%) in the permissive hypotension compared with 544 of 1242 (43.8%) in the usual care group had died (absolute risk difference, 2.85%; 95% CI, 6.75 to 1.05; P=.15) (unadjusted relative risk, 0.93; 95% CI, 0.85-1.03). When adjusted for prespecified baseline variables, the odds ratio for 90-day mortality was 0.82 (95% CI, 0.68 to 0.98). Serious adverse events were reported for 79 patients (6.2%) in the permissive care group and 75 patients (5.8%) in the usual care group. The most common serious adverse events were acute renal failure (41 [3.2%] vs 33 [2.5%]) and supraventricular cardiac arrhythmia (12 [0.9%] vs 13 [1.0%]).
Conclusions and Relevance Among patients 65 years or older receiving vasopressors for vasodilatory hypotension, permissive hypotension compared with usual care did not result in a statistically significant reduction in mortality at 90 days. However, the confidence interval around the point estimate for the primary outcome should be considered when interpreting the clinical importance of the study.
DOI: 10.1001/jama.2020.0930
Source: https://jamanetwork.com/journals/jama/fullarticle/2761427