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

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.

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