References

rmt

Общая реаниматология

General Reanimatology

1813-97792411-7110

FSBI "SRIGR" RAMS

10.15360/1813-9779-2022-5-60-77

rmt-2267

Research Article

ОБЗОРЫ И КРАТКИЕ СООБЩЕНИЯ

REVIEWS & SHORT COMMUNICATIONS

Применение инотропных препаратов и вазопрессоров в реаниматологии и периоперационной медицине: доказательный подход (обзор)

Inotropes and Vasopressors Use in Critical Care and Perioperative Medicine: Evidence-Based Approach (Review)

Беллетти

А.

Belletti

Алессандро Беллетти - Отделение анестезиологии и интенсивной терапии.

20132, Милан, Виа Олжиттина, д. 60

Alessandro Belletti - Department of Anesthesia and Intensive Care.

60 Via Olgettina, 20132 Milan

belletti.alessandro@hsr.it

Аццолини

М. Л.

Azzolini

M. L.

Мария Луиза Аццолини - Отделение анестезиологии и интенсивной терапии.

20132, Милан, Виа Олжиттина, д. 60

Maria Luisa Azzolini - Department of Anesthesia and Intensive Care.

60 Via Olgettina, 20132 Milan

Балдетти

Л.

Baldetti

Лука Балдетти - Отделение анестезиологии и интенсивной терапии.

20132, Милан, Виа Олжиттина, д. 60

Luca Baldetti - Coronary Care Unit, Department of Cardiology.

60 Via Olgettina, 20132 Milan

Ландони

Дж.

Landoni

Джованни Ландони - Отделение анестезиологии и интенсивной терапии НИИ San Raffaele.

20132, Милан, Виа Олжиттина, д. 60; 20132, Милан, Виа Олжиттина, д. 58

Giovanni Landoni - Department of Anesthesia and Intensive Care IRCCS SRSI.

60 Via Olgettina, 20132 Milan; 58 Via Olgettina, 12132 Milan

Франко

А.

Franco

Анналиса Франко - Отделение анестезиологии и интенсивной терапии.

20132, Милан, Виа Олжиттина, д. 60

Annalisa Franco - Department of Anesthesia and Intensive Care.

60 Via Olgettina, 20132 Milan

Дзангрилло

А.

Zangrillo

Альберто Дзангрилло - Отделение анестезиологии и интенсивной терапии НИИ San Raffaele.

20132, Милан, Виа Олжиттина, д. 60; 20132, Милан, Виа Олжиттина, д. 58

Alberto Zangrillo - Department of Anesthesia and Intensive Care IRCCS SRSI.60 Via Olgettina, 20132 Milan; 58 Via Olgettina, 12132 Milan

Научно-исследовательский институт San RaffaeleИталияIRCCS San Raffaele Scientific InstituteItaly

Научно-исследовательский институт San Raffaele; Университет Vita-Salute San Raffaele, Медицинская школаИталияIRCCS San Raffaele Scientific Institute; Vita-Salute San Raffaele University, School of MedicineItaly

Научно-исследовательский институт San Raffaele; Университет Vita-Salute San Raffaele, Медицинская школаРоссияIRCCS San Raffaele Scientific Institute; Vita-Salute San Raffaele University,School of MedicineRussian Federation

2022

25102022

1856077

2022

Беллетти А., Аццолини М.Л., Балдетти Л., Ландони Д., Франко А., Дзангрилло А.

Belletti A., Azzolini M.L., Baldetti L., Landoni G., Franco A., Zangrillo A.

Данная работа распространяется под лицензией Creative Commons Attribution 4.0.

This work is licensed under a Creative Commons Attribution 4.0 License.

https://www.reanimatology.com/rmt/article/view/2267

Пациентам в критическом состоянии, а также при проведении крупных хирургических операций часто требуется введение инотропных препаратов и вазопрессоров. На сегодняшний день применяются препараты с подобным эффектом, принадлежащие к нескольким группам, среди которых катехоламины, ингибиторы фосфодиэстеразы-3, вазопрессин и его аналоги, а также сенсибилизаторы кальция.

В представленном обзоре рассматриваются современные данные и, особенно, последние рандомизированные контролируемые исследования (РКИ), посвященные использованию инотропных препаратов у пациентов в периоперационном периоде и в крайне тяжелом состоянии.

Несмотря на широкое применение инотропных препаратов в анестезиологии и интенсивной терапии, данные об их безопасности и эффективности немногочисленны. Обсервационные исследования свидетельствуют о том, что введение инотропных препаратов может повысить летальность у пациентов во время кардиохирургических операций, при острой сердечной недостаточности или кардиогенном шоке. Однако, рандомизированные контролируемые исследования их применения в условиях оказания неотложной помощи не подтвердили эти выводы.

Применение адреналина связывали с увеличением летальности, особенно при кардиогенном шоке, однако рандомизированные исследования не выявили данных о повышении летальности на фоне его введения. Нарушение функции левого желудочка традиционно считалось противопоказанием к применению норадреналина, но недавние исследования показали, что у пациентов с кардиогенным шоком он оказывает гемодинамические эффекты, сходные с адреналином. Допамин не имеет дополнительных преимуществ перед норадреналином, повышает риск тахиаритмии и может увеличить летальность при кардиогенном шоке. Ингибиторы фосфодиэстеразы-3 (ФДЭ-3) эквивалентны катехоламинам с точки зрения основных исходов. Левосимендан является наиболее изученным за последние 30 лет инотропом, но, несмотря на оптимистические результаты ранних исследований, многоцентровые РКИ высокого качества не продемонстрировали его преимуществ в сравнении с другими препаратами. Нет ни одного высококачественного РКИ, четко демонстрирующего превосходство одного препарата над другим. В целом, современные данные свидетельствуют о том, что исход не зависит от вида применяемого инотропного препарата, если достигнуты целевые гемодинамические показатели.

Наконец, в последние годы все более популярной становится механическая поддержка кровообращения (МПК). Благодаря совершенствованию технологий происходит постоянное повышение безопасности и биосовместимости применяемых с этой целью устройств. Теоретически устройства МПК имеют преимущества перед инотропными препаратами, но их использование ограничено вследствие стоимости, доступности и инвазивности.

Заключение. Будущие исследования должны определить безопасность, эффективность и экономическую целесообразность приоритетного применения МПК по сравнению с инотропными препаратами у пациентов с острой сердечно-сосудистой недостаточностью.

Inotropes and vasopressors are frequently required in critically ill patients and in patients undergoing major surgery. Several molecules are currently available, including catecholamines, phosphodiesterase-3 inhibitors, vasopressin and its analogues, and calcium sensitizers.

We will review current evidence on inotropes use in perioperative and critically ill patients, with focus on most recent randomized controlled trials (RCTs).

Despite being widely used in anesthesia and intensive care, evidences on safety and efficacy of inotropes are scarce. Data from observational studies suggest that inotropes administration may increase mortality in cardiac surgery, acute heart failure, and cardiogenic shock patients. However, randomized controlled trials did not confirm these findings in acute care settings.

Epinephrine has been associated with increased mortality especially in cardiogenic shock, but randomized trials failed to show evidence of increased mortality associated with epinephrine use. Norepinephrine has been traditionally considered contraindicated in patients with ventricular dysfunction, but recent trials suggested hemodynamic effects similar to epinephrine in patients with cardiogenic shock. Dopamine has no additional advantages over norepinephrine and increases the risk of tachyarrhythmias and may increase mortality in cardiogenic shock. Phosphodiesterase-3 (PDE-3) inhibitors are equivalent to catecholamines in terms of major outcomes. Levosimendan is the most investigated inotrope of the last 30 years, but despite promising early studies, high-quality multicenter RCTs repeatedly failed to show any superiority over available agents. There is no highquality RCT clearly demonstrating superiority of one agent over another. In summary, current evidence suggest that the choice of inotrope is unlikely to affect outcome, as long as the target hemodynamic goals are achieved.

Finally, in recent years, mechanical circulatory support (MCS) has become increasingly popular. Thanks to improvement in technology, the safety and biocompatibility of devices are constantly growing. MCS devices have theoretical advantages over inotropes, but their use is limited by costs, availability, and invasiveness.

Conclusion. Future studies should investigate safety, efficacy, and cost-effectiveness of primary MCS versus primary inotropes in patients with acute cardiovascular failure.

управление гемодинамикойинотропные препаратывазопрессорыкатехоламинышокинтенсивная терапиялетальность

hemodynamic managementinotropesvasopressorscatecholaminesshockintensive caremortality

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The authors declare that there are no conflicts of interest present.