浅谈血管活性药物

•
Milri LCO
Levo
• Milri LCO
Cochrane Database of Systematic Reviews 2015, Issue 3. Art. No.: CD009515. DOI: 10.1002/14651858.CD009515.pub2.
• ICU
Dobut
Milri Levo
High dose 75ug✕60min 0.75ug/kg/min✕35hr 55% 36hr
Hoffman TM, Wernovsky G, Atz AM, Kulik TJ, Nelson DP, Chang AC,et al. Efficacy and safety of milrinone in preventing low cardiac output syndrome in infants and children after corrective surgery for congenital heart disease. Circulation. 2003;107(7):996–1002.
Echo
CVP PCWP
§ § § §
+
LCOS LCO SVRI LCO PVRI
25-75ug/kg iv 15min 0.25-0.75ug/kg/min
§ § § §
§ § § § § !" = !#$
+
β1
LCOS
ESV 2-20ug/kg/min
&'( &) *&( *&)
LCO SVRI
MILRI DOPA 3 0 DOBUT ADR NE 4
SVR
LCO
MIlri
SVRI
LCO
§
n=9
8
Milri+Dopa n=2 Milri+Adr n=3 Milri+Dobut n=1 Milri+Dopa+Dobut n=1 Milri+Dopa+Adr n=1 Milri+Dobut n=1 Dobut+Adr n=1
§
10
7
Adr+NE n=1 Milri+Dopa n=1 Dopa+Adr+Milri+VP n=1
SVR
2
2 1
MILRI
DOPA
DOBUT
ADR
NE
VP
LCO
Dopa
Adr
NE
SVRI
LCO
§
n=9
5 5
NE+Dopa n=2 NE+VP n=2 Adr+Milri n=2 NE+Dopa+Milri n=1 Dopa+VP n=1 Dopa+Dobut n=1
§ §
§ § § § §
Dopa or NE
Cochrane Database of Systematic Reviews 2015, Issue 3. Art. No.: CD009515. DOI: 10.1002/14651858.CD009515.pub2.
• •
Levo Dobut Dobut
Milri Milri
Arch Dis Child 2011; 96 :1180–1186. doi:10.1136/archdischild-2011-300370
•
Dopa
Dopa
Chinese Medical Journal ¦ April 20, 2015 ¦ Volume 128 ¦ Issue 8
SVRI
LCO
n=1 1 Dopa NE Adr
§
13
n=15 Dopa+Adr n=5 Dopa+NE n=2 Dopa+Adr+NE n=2 Dopa+Adr+Milri n=1 Dobut+NE n=1 Dopa+Dobut+NE n=1
CICU
IS VIS
IS=Dopa+Dobut+100✕Adr VIS=IS+10 ✕Milri+100 ✕NE +10000 ✕VP
Dopa Dobut Adr
VAS NE Milri
• Wernovsky G, Wypij D, Jonas RA et al (1995) Postoperative course and hemodynamic profile after the arterial switch opera- tion in neonates and infants. A comparison of lowflow car- diopulmonary bypass and circulatory arrest. Circulation 92:2226–2235 • Gaies MG, Gurney JG, Yen AH et al (2010) Vasoactive-inotropic score as a predictor of morbidity and mortality in infants after cardiopulmonary bypass. Pediatr Crit Care Med 11:234–238
or
n=15
n=12
n=5
n=1
n=3
n=10LCO来自§n=510
Dopa n=4 Dobut n=1 n=10 Milri+Dopa n=2 Milri+Dopa+Adr n=2
§
7
5 4
Milri+Dopa+Dobut n=2 Dopa+Adr n=2 Dopa+Dobut n=1 Milri+Dopa+Dobut+Adr+NE n=1
DOBUTAMINE VS OTHERS
• • Levosimenden Milri Levo Dobut
• Milri Dobut • Dobut • Milri SVRI
Pediatr Crit Care Med 2018; XX:00–00
Cochrane Database of Systematic Reviews 2015, Issue 3. Art. No.: CD009515. DOI: 10.1002/14651858.CD009515.pub2.
Adr + +
Vasodilator
Levo Nip NTG Reg CCBs
Inodilator
Milri
Inotropes
Dobut Dopa
Vasopressor
NE Vasopressin
Inodilator Inotropes Vasopressor
L
Q
O
BNP Lac ScvO2
1 3 3
2
MILRI
DOPA
DOBUT
ADR
NE
VP
Dopa
NE
VP
NE
• NE ESV β1 • NE Ea/Ees Ea Ees Ees LVESP Ea
Crit Care Med 2018; 46:e17–e25 DOI: 10.1097/CCM.0000000000002772
•
MILRI DOPA 2 4 5
0 DOBUT ADR NE
Milri
Dopa
Adr
§ § § § §
100-300ng/ml 25% 0.2ug/kg/min
§ § § §
α1 β1 Dopa
SVRI
ESC
Dobut
ESC
•
NE
NE
Dobut
•
NE+Dobut
Adr
•
• ESICM 2016 NE Dobut
Milri/Levo • • •
Intensive Care Med (2016) 42:147–163 DOI 10.1007/s00134-015-4041-5
• • ESC NE
• HR
dopa
• HR NE • NE
CJEM 2015;17(S1):1–16 DOI 10.1017/cem.2014.77
(Pediatr Crit Care Med 2018; 19:237–244) DOI: 10.1097/PCC.0000000000001445
§ § § §
0.0004U/kg/min NE V1 Rp/Rs
Norwood I
& ASO
§ § § 48hr §
Pediatr Crit Care Med 2012; 13:300–304) DOI: 10.1097/PCC.0b013e31822f1753
LCO risk Bailey JM, Miller BE, Lu W, Tosone SR, Kanter KR, Tam VK. The pharmacokinetics of milrinone in pediatric patients after cardiac surgery. Anesthesiology. 1999;90(4):1012–8.
MILRI DOPA
1 DOBUT ADR NE
LCO
Dopa
SVRI
LCO
§
n=2
14
1 Dopa Adr Dobut 2 Dopa Milri Dobut
§
11
n=14
Milri+Dopa n=7 Milri+Adr n=3 Milri+Dopa+Adr n=1 Milri+Dopa+Dobut n=3
World Journal for Pediatric and Congenital Heart Surgery 2016, Vol. 7(1) 25-31
Chinese Medical Journal ¦ April 20, 2015 ¦ Volume 128 ¦ Issue 8
LCO n=16
DA β α
SVR PAP PVR T
• HR
dopa
• HR NE • NE
•
AI --Dopa
• Dopa Dobut
(Crit Care Med 2017; 45:1061–1093) DOI: 10.1097/CCM.0000000000002425
HAI
§ § § §
>=3 Dopa
Fontan
§ § §
World Journal for Pediatric and Congenital Heart Surgery 2016, Vol. 7(1) 43-48 DOI: 10.1177/2150135115614574
Fontan
§ § §
World Journal for Pediatric and Congenital Heart Surgery 2016, Vol. 7(1) 43-48 DOI: 10.1177/2150135115614574
= +, = !. − 1
!+,
-
• 50ug/kg iv ->0.5ug/kg/min ✕ 2hr • CI SVI DO 2 • SVRI PAP Bailey et al • 50ug/kg iv >5min • MAP 12% • CI 18% Low dose 25ug/kg✕60min 0.25ug/kg/min✕35hr
•
SVR
LCOS
Dopa Arch Dis Child 2011;96 :1180–1186. doi:10.1136/archdischild-2011-300370
§ §
SVR Dopa
LCOS Adr
World Journal for Pediatric and Congenital Heart Surgery 2016, Vol. 7(1) 25-31. DOI: 10.1177/2150135115606626
• Adr NE+Dobut • Adr • Adr • Adr CO2 GAP
(Crit Care Med 2011; 39:450 – 455) DOI: 10.1097/CCM.0b013e3181ffe0eb
+2ATP+2ADP+2Pi+2NAD+ ——>2
Adr Na+-K+ ATPase
ROSC Adr ROSC
• Adr
•
ROSC ROSC Adr
•
(Pediatr Crit Care Med 2016; 17:e502–e512) DOI: 10.1097/PCC.0000000000000954
• Adr
(Crit Care Med 2017; 45:1061–1093) DOI: 10.1097/CCM.0000000000002425
+4ATP+2NADH+2H+
Curr Opin Crit Care 2017, 23:348 – 354 DOI:10.1097/MCC.0000000000000423
§ 5ug/kg/min § 5-10ug/kg/min § >10ug/kg/min § >7.5ug/kg/min § § §