依照2008戰勝敗血症臨床指引,Norepinephrine or dopamine centrally administered are the initial vasopressors of choice.(level of evidence , 1C)。 

不過今年新英格蘭期刊發一表了一篇針對休克病患使用dopamine 或 levophed ,比較兩者在死亡率有無差異!!

此篇研究的背景: Both dopamine and norepinephrine are recommended as first-line vasopressor agents
in the treatment of shock. There is a continuing controversy about whether one agent
is superior to the other.

研究方法: In this multicenter, randomized trial, we assigned patients with shock to receive
either dopamine or norepinephrine as first-line vasopressor therapy to restore and
maintain blood pressure. When blood pressure could not be maintained with a dose
of 20 μg per kilogram of body weight per minute for dopamine or a dose of 0.19 μg
per kilogram per minute for norepinephrine, open-label norepinephrine, epinephrine,
or vasopressin could be added. The primary outcome was the rate of death at
28 days after randomization
; secondary end points included the number of days
without need for organ support and the occurrence of adverse events.

多醫學中心隨機分配研究,一組是dopamine 20 mcq/kg/min(最大劑量) 另一組是levophed 0.19mcq/kg/min(最大劑量),當實驗組或控制組仍無法控制血壓的話再加上公開標示的levophed 。公開標示epinephrine or vasopressin被用在危急治療;主要實驗終點是28天死亡率;次要實驗終點是不需使用藥物或器官支持(呼吸器,CRRT)的天數。如果病患在實驗前已使用升壓劑,就須使用實驗藥物來取代;如果實驗前以已使用dopamine,在實驗藥物介入後,dopamine如果不能被停止的話,就須使用公開標示的levophed來取代。公開標示的dopamine在任何時候是不准使用的。

結果:  The trial included 1679 patients, of whom 858 were assigned to dopamine and 821
to norepinephrine. The baseline characteristics of the groups were similar. There
was no significant between-group difference in the rate of death at 28 days (52.5%
in the dopamine group and 48.5% in the norepinephrine group; odds ratio with
dopamine, 1.17; 95% confidence interval, 0.97 to 1.42; P = 0.10). However, there were
more arrhythmic events among the patients treated with dopamine than among
those treated with norepinephrine (207 events [24.1%] vs. 102 events [12.4%], P<0.001).
A subgroup analysis showed that dopamine, as compared with norepinephrine,
was associated with an increased rate of death at 28 days among the 280 patients
with cardiogenic shock but not among the 1044 patients with septic shock or the 263
with hypovolemic shock (P = 0.03 for cardiogenic shock, P = 0.19 for septic shock,
and P = 0.84 for hypovolemic shock, in Kaplan–Meier analyses).

實驗蒐羅了1679位病人,其中858被分配至dopamine,821位分至levophed。兩組別的基本特徵差不多,兩組28天死亡率沒有統計學的差異;dopamine組有較多的心整不整事件(207 events [24.1%] vs. 102 events [12.4%], P<0.001);在次群分析中,dopamine組較levophed組在心因性休克病患會增加28天死亡率,而敗血性及低血容積性休克並無差異。

1.bmp 

     無論是28天,6,12個月死亡率,在加護病房死亡率,在醫院死亡率兩組無差異。

2.bmp 

28天存活分析圖表可知 levophed 較 dopamine  有較高的存活率,但無統計學上的差異

3.bmp 

在次要結果分析中,在器官支持的天數,使用公開標示levophed的天數, 住院天數, 藥物副作用次數(除心律不整外)兩組無明顯差異。

4.bmp 

再次群分析中,所有休克病患無論使用dopamine或levophed 死亡率無差異;只有在心因性休克病患levophed的使用可能有好處。

結論: Although there was no significant difference in the rate of death between patients
with shock who were treated with dopamine as the first-line vasopressor agent and
those who were treated with norepinephrine, the use of dopamine was associated
with a greater number of adverse events.

雖然死亡率在兩組無差異,但doapmine組別早期死亡率在心因性休克病患較levophed組別高,作者認為與其心率過快導致心臟缺血事件有過,儘管之前研究認為dopamine較能維持心輸出量,但真正造成死亡率增加的原因並不確定。作者的結果也挑戰了之前AHA/ACC的建議-dopamine as the first-choice agent to increase arterial pressure
among patients who have hypotension as a result of an acute myocardial infarction.(心肌梗塞導致的血壓過低,dopamine是第一線用藥)

Adapted from NEJM 2010 Mar 4;362(9):779-89.

 

 

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