脓毒症致心源性休克:诊断和治疗的争议和证据缺口。

IF 3.8 2区 医学 Q1 CRITICAL CARE MEDICINE Journal of Intensive Care Pub Date : 2025-01-02 DOI:10.1186/s40560-024-00770-y
Ryota Sato, Daisuke Hasegawa, Stephanie Guo, Abdulelah E Nuqali, Jesus E Pino Moreno
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引用次数: 0

摘要

脓毒症通常导致血管截瘫和心脏高动力状态,治疗的重点是恢复血管张力。然而,败血症也可能导致可逆性心肌功能障碍,特别是在患有心脏病的老年人中。生存脓毒症运动指南推荐对脓毒症休克合并心功能障碍和持续灌注不足的患者使用多巴酚丁胺和去甲肾上腺素或单独使用肾上腺素,尽管有充分的液体复苏和稳定的血压。然而,这些指南中心功能障碍和灌注不足的定义仍然存在争议,导致临床解释不一。尽管恢复了足够的前负荷和后负荷,但持续低灌注的心功能障碍通常被认为是心源性休克。因此,脓毒症合并新发心肌功能障碍或因败血症性心肌病导致原有心肌功能障碍加重,导致心源性休克,可定义为“败血症性心源性休克(SICS)”。众所周知,SICS与死亡率显著升高有关。心功能障碍的历史是一个强有力的预测因素,强调了在人口老龄化和心血管疾病患病率上升的情况下精确诊断和管理的必要性。因此,与单纯感染性休克不同,早期有创肺动脉导管(PAC)血流动力学监测可能对SICS患者有益。虽然对所有脓毒症患者进行常规PAC监测是不切实际的,但超声心动图可能是一种有用的高风险个体筛查工具。如果超声心动图提示心源性休克,可能需要持续监测PAC。直肌力在SICS中的作用仍不确定。严重病例可考虑机械循环支持(MCS),因为大剂量的血管加压剂和肌力药物与较差的结果相关。正确的患者选择是改善MCS预后的关键。参与心源性休克小组的多学科方法可能是有益的。总之,解决SICS诊断和管理方面的证据差距至关重要。超声心动图的筛选,先进的监测与PAC,并仔细选择患者的MCS是重要的最佳患者护理。
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Sepsis-induced cardiogenic shock: controversies and evidence gaps in diagnosis and management.

Sepsis often leads to vasoplegia and a hyperdynamic cardiac state, with treatment focused on restoring vascular tone. However, sepsis can also cause reversible myocardial dysfunction, particularly in the elderly with pre-existing heart conditions. The Surviving Sepsis Campaign Guidelines recommend using dobutamine with norepinephrine or epinephrine alone for patients with septic shock with cardiac dysfunction and persistent hypoperfusion despite adequate fluid resuscitation and stable blood pressure. However, the definition of cardiac dysfunction and hypoperfusion in these guidelines remains controversial, leading to varied clinical interpretations. Cardiac dysfunction with persistent hypoperfusion despite restoring adequate preload and afterload is often considered a cardiogenic shock. Therefore, sepsis complicated by new-onset myocardial dysfunction or worsening of underlying myocardial dysfunction due to sepsis-induced cardiomyopathy, resulting in cardiogenic shock, can be defined as "Sepsis-induced cardiogenic shock (SICS)". SICS is known to be associated with significantly higher mortality. A history of cardiac dysfunction is a strong predictor of SICS, highlighting the need for precise diagnosis and management given the aging population and rising cardiovascular disease prevalence. Therefore, SICS might benefit from early invasive hemodynamic monitoring with a pulmonary artery catheter (PAC), unlike those with septic shock alone. While routine PAC monitoring for all septic patients is impractical, echocardiography could be a useful screening tool for high-risk individuals. If echocardiography indicates cardiogenic shock, PAC might be warranted for continuous monitoring. The role of inotropes in SICS remains uncertain. Mechanical circulatory support (MCS) might be considered for severe cases, as high-dose vasopressors and inotropes are associated with worse outcomes. Correct patient selection is the key to improving outcomes with MCS. Engaging a cardiogenic shock team for a multidisciplinary approach can be beneficial. In summary, addressing the evidence gaps in SICS diagnosis and management is crucial. Echocardiography for screening, advanced monitoring with PAC, and careful patient selection for MCS are important for optimal patient care.

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来源期刊
Journal of Intensive Care
Journal of Intensive Care Medicine-Critical Care and Intensive Care Medicine
CiteScore
11.90
自引率
1.40%
发文量
51
审稿时长
15 weeks
期刊介绍: "Journal of Intensive Care" is an open access journal dedicated to the comprehensive coverage of intensive care medicine, providing a platform for the latest research and clinical insights in this critical field. The journal covers a wide range of topics, including intensive and critical care, trauma and surgical intensive care, pediatric intensive care, acute and emergency medicine, perioperative medicine, resuscitation, infection control, and organ dysfunction. Recognizing the importance of cultural diversity in healthcare practices, "Journal of Intensive Care" also encourages submissions that explore and discuss the cultural aspects of intensive care, aiming to promote a more inclusive and culturally sensitive approach to patient care. By fostering a global exchange of knowledge and expertise, the journal contributes to the continuous improvement of intensive care practices worldwide.
期刊最新文献
Early systemic insults following severe sepsis-associated encephalopathy of critically ill patients: association with mortality and awakening-an analysis of the OUTCOMEREA database. Age-dependent differences in the association between blood interleukin-6 levels and mortality in patients with sepsis: a retrospective observational study. Impact of hyper- and hypothermia on cellular and whole-body physiology. Intravenous branched-chain amino acid administration for the acute treatment of hepatic encephalopathy: a systematic review and meta-analysis. Sepsis-induced cardiogenic shock: controversies and evidence gaps in diagnosis and management.
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