血管加壓素與危重病

血管加壓素與危重病Contents

Case

report

The

picture

of

AVP

AVP-R

and

antagonists

Related

agents

Clinical

use

Case

1XX,

M,

60yrs

服DDV

300ml

24小時(shí)轉(zhuǎn)入我院ICU

被發(fā)現(xiàn)時(shí)昏迷,大汗,瞳孔針尖樣

入當(dāng)?shù)蒯t(yī)院氣管插管MV后洗胃4h

shock

DOPA轉(zhuǎn)入時(shí)20ug/kg/min24小時(shí)應(yīng)用阿托品45mgCase

report

Case

2XX,

F,

31yrs

足月經(jīng)陰分娩后陰道出血分娩后1.5小時(shí)CPR

CPR5分鐘成功

分娩后3小時(shí)子宮全切術(shù)分娩后5小時(shí)轉(zhuǎn)入ICU:七竅出血持續(xù)低血壓7小時(shí)NE2-4,

DOPA10-20,

AVP

2-8U/h

入ICU7小時(shí)FFP

3200ml冷沉淀20U

RBC32U血小板1人份問題Why?When?Who

?Dose?AVP合成

釋放

代謝合成:視上核和室旁核儲(chǔ)存:垂體后葉代謝:肝臟和腎臟半衰期10-35min

受體分布作用V1a血管血管平滑肌,肝臟,腎小球出球小動(dòng)脈收縮血管,促進(jìn)肝糖元分解,增加血小板聚集,增加腎小球灌注壓,

GFR增加V2腎臟腎集合管促進(jìn)水重吸收,抗利尿V3(V1b)垂體垂體刺激ACTH釋放加壓素受體拮抗劑

V2R

Antagonist

(Tolvaptan托伐普坦,商品名-蘇麥卡,

satavaptan,

lixivaptan)

V1a-V2RAntagonist

(conivaptan)

肝硬化腹水,心衰,

SIADHRelated

agents

加壓素(vasopressin)血管加壓素精氨酸加壓素(AVP)抗利尿激素(ADH)抗利尿作用/血管平滑肌收縮作用特利加壓素(terlipresssin,

t-GLVP)一種新型人工合成血管加壓素

垂體后葉素

含催產(chǎn)素和加壓素

收縮子宮/抗利尿/升高血壓

豬牛羊腦神經(jīng)垂體中提取Related

agents

鞣酸加壓素(長效尿崩停)

去氨加壓素(彌凝)抗利尿作用/血管加壓作用比

約為加壓素的1200-3000倍Clinicaluse.

中樞性尿崩癥CDI

CPR

Septic

shockAVPandCPRBecausetheeffectsofAVPhavenotbeenshowntodifferfromthoseofE

inCA,1doseofAVP40unitsIV/IOmayreplaceeitherthe1st

or2nd

doseofE

inthetreatmentofCA(ClassIIb,LOEA).

加壓素40u

1次IV/IO可用于替代CPR時(shí)首劑或第二劑副腎素The

introduction

of

AVP

AVPimprovesvitalorganbloodflowduringclosed-chestcardiopulmonaryresuscitationinpigs

Circulation.1995;91:215–221AVPandshockAVP0.03u/mincanbeaddedtoNEwithintentofeitherraisingMAPordecreasingNEdosage(UG).在NE應(yīng)用的基礎(chǔ)上,感染性休克病人可加用AVP

0.03u/min以進(jìn)一步提高M(jìn)AP或減少NE用量AVPandshockLowdoseAVPisnotrecommendedasthesingleinitialvasopressorfortreatmentofsepsis-inducedhypotension

不推薦小劑量加壓素作為膿毒癥性低血壓?jiǎn)为?dú)的初始升壓藥物AVPandshockAVPdoses>0.03-0.04u/minshouldbereservedforsalvagetherapy(failuretoachieveadequateMAPwithothervasopressoragents)(UG).

高劑量AVP(>0.03-0.04u/min)可用于膿毒性休克病人其他升壓藥物效果不滿意的補(bǔ)救性治療RationalerelativevasopressindeficiencyAVPconcentrationsareelevatedinearlyS.

Shock,butdecreasetonormalrangeinthemajorityofpatientsbetween24and48hrsasshockcontinues.Inthepresenceofhypotension,vasopressinwouldbeexpectedtobeelevatedTiming

TheVASSTtrialanRCT:

comparingNEtoNE+AVP0.03U/minnodifferenceinoutcome

Anaprioridefinedsubgroupanalysisdemonstratedthatsurvivalamongpatientsreceiving<15μg/minNEatthetimeofrandomizationwasbetterwiththeadditionofAVP;NEnglJMed2008;358:877–887Adverse

effectsHigherdosesofvasopressinhavebeenassociatedwithcardiac,digital,andsplanchnicischemiaandShouldbereservedforsituationswherealternativevasopressorshavefailed

CritCareMed2003;31:1394–1398