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EARLの医学ノート

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敗血症をメインとした集中治療,感染症,呼吸器のノート.Stop Sepsis, Save Lives.

敗血症性ショックでのDOA vs NA,DOAで死亡率・不整脈発生率高い【メタ解析】

 敗血症性ショックにおけるノルアドレナリンとドパミンの論争が続いていた.SSCGではいずれでもよいとしているが,病態生理学的にはノルアドレナリンの方が有用とする意見が多く,臨床的にもノルアドレナリンが死亡率が低いとする報告がでてきていた.メタ解析ではJ Intensive Care Med online March 24, 2011が既に出ており,ノルアドレナリンの方が有意に死亡率が低いとの報告であった(6研究,N=2043).

 本ブログにおいては敗血症性ショック(Warm Shock)の急性期治療におけるEGDTと昇圧剤についてまとめている.⇒くわしくはこちら

 今回Critical Care Medicineからのメタ解析.11研究,N=2768.結論は,ドパミンの方が死亡率,不整脈発生率がノルアドレナリンより高いという報告で,ノルアドレナリンを支持する内容.これが今後のEBMになっていくと思われ,敗血症性ショックではノルアドレナリンが第一選択に推奨され,ドパミンは推奨されない.

De Backer, Daniel MD, PhD; Aldecoa, Cesar MD; Njimi, Hassane MSc, PhD; Vincent, Jean-Louis MD, PhD, FCCM
Dopamine versus norepinephrine in the treatment of septic shock: A meta-analysis
Critical Care Medicine:
March 2012 - Volume 40 - Issue 3 - p 725–730

Objectives: There has long-been controversy about the possible superiority of norepinephrine compared to dopamine in the treatment of shock. The objective was to evaluate the effects of norepinephrine and dopamine on outcome and adverse events in patients with septic shock.

Data Sources: A systematic search of the MEDLINE, Embase, Scopus, and CENTRAL databases, and of Google Scholar, up to June 30, 2011.

Study Selection and Data Extraction: All studies providing information on the outcome of patients with septic shock treated with dopamine compared to norepinephrine were included. Observational and randomized trials were analyzed separately. Because time of outcome assessment varied among trials, we evaluated 28-day mortality or closest estimate. Heterogeneity among trials was assessed using the Cochrane Q homogeneity test. A Forest plot was constructed and the aggregate relative risk of death was computed. Potential publication bias was evaluated using funnel plots.

Methods and Main Results: We retrieved five observational (1,360 patients) and six randomized (1,408 patients) trials, totaling 2,768 patients (1,474 who received norepinephrine and 1,294 who received dopamine). In observational studies, among which there was significant heterogeneity (p < .001), there was no difference in mortality (relative risk, 1.09; confidence interval, 0.84–1.41; p = .72). A sensitivity analysis identified one trial as being responsible for the heterogeneity; after exclusion of that trial, no heterogeneity was observed and dopamine administration was associated with an increased risk of death (relative risk, 1.23; confidence interval, 1.05–1.43; p < .01). In randomized trials, for which no heterogeneity or publication bias was detected (p = .77), dopamine was associated with an increased risk of death (relative risk, 1.12; confidence interval, 1.01–1.20; p = .035). In the two trials that reported arrhythmias, these were more frequent with dopamine than with norepinephrine (relative risk, 2.34; confidence interval, 1.46–3.77; p = .001).

Conclusions: In patients with septic shock, dopamine administration is associated with greater mortality and a higher incidence of arrhythmic events compared to norepinephrine administration.
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by DrMagicianEARL | 2012-02-21 19:01 | 敗血症 | Comments(0)

by DrMagicianEARL