- 學位論文
在急診早期使用正腎上腺素對敗血症休克的影響
Early use of norepinephrine in septic shock in the emergency department
摘要
研究背景及目標 目前國際敗血症休克治療指引建議先給予復甦輸液治療，輸液劑量為30ml/kg，若給予復甦輸液後仍低血壓，則考慮給予升壓劑治療。最新的敗血症治療指引更新版說明，可以在完成30ml/kg預定復甦輸液劑量之前，在給予復甦輸液的同時，就給予升壓劑，但並未說明給予升壓劑的時間點。此外，30mL/kg的預定復甦輸液劑量取決於專家共識。 本研究的目標是希望釐清在敗血症休克的病人中，於首次發生低血壓的一小時內就給予升壓劑正腎上腺素，是否對臨床結果有好處。 研究材料及方法 本研究是回溯性世代研究，藉由華碩 Lumos EMR Research platform中山醫學大學附設醫院於2019 年1月1日到 2022年12 月 31日間急診就醫病人，診斷敗血症休克，並於急診使用正腎上腺素。 首次低血壓到使用正腎上腺素的時間在一小時內者，定義為實驗組，而大於一小時使用正腎上腺素者定義為對照組。兩組會進行傾向性評分匹配（Propensity score matching, PSM）。 研究結果 經過配對後，實驗組與對照組各有50人。主要結果是28天死亡率，研究發現實驗組的死亡率較低，但未達到統計顯著意義。次要結果是組織灌注治療目標達標，研究發現實驗組的達標比率較高，但未達到統計顯著意義。其他研究指出，在敗血症休克的病患中淨液體輸入量越高，可能造成預後越差。本研究發現，實驗組（一小時內給予正腎上腺素）使用較少復甦輸液，淨液體輸入量也比較少，有達到統計顯著意義。 研究結論 在敗血症休克的病人中，一小時內給予正腎上腺素並未造成28天死亡率的差異，並能減少淨液體輸入量以及復甦輸液量。至於非常早期使用升壓劑是否能改善預後，仍需進一步的研究。
並列摘要
Background and Objectives The current international guidelines for the treatment of septic shock recommend administering resuscitation fluids first, with a fluid volume of 30 ml/kg. If hypotension persists after resuscitation fluids, the use of vasopressors should be considered. The latest updated version of the sepsis treatment guidelines indicates that vasopressors can be administered concurrently with resuscitation fluids, even before completing the predetermined 30 ml/kg resuscitation fluid volume, but it does not specify the exact timing for administering vasopressors. Furthermore, the predetermined resuscitation fluid volume of 30 ml/kg is based on expert consensus. The aim of this study is to clarify whether administering the vasopressor norepinephrine within one hour of the first occurrence of hypotension in patients with septic shock is beneficial to clinical outcomes. Materials and Methods This study is a retrospective cohort study, utilizing the ASUS Lumos EMR Research platform. It includes patients from the Chung Shan Medical University Hospital who visited the emergency department between January 1, 2019, and December 31, 2022, were diagnosed with septic shock, and received norepinephrine in the emergency department. Patients who received norepinephrine within one hour of the first occurrence of hypotension were defined as the experimental group, while those who received norepinephrine more than one hour after the first occurrence of hypotension were defined as the control group. Propensity score matching (PSM) will be performed for the two groups. Results After matching, there were 50 patients in both the experimental group and the control group. The primary outcome was the 28-day mortality rate. The study found that the mortality rate in the experimental group was lower, but this difference was not statistically significant. The secondary outcome was the achievement of tissue perfusion treatment targets. The study found that the rate of achieving these targets was higher in the experimental group, but this difference was also not statistically significant. Other studies have indicated that higher net fluid input in septic shock may be associated with worse outcomes. Our study found that the experimental group (those who received norepinephrine within one hour) used less resuscitation fluid and had a lower net fluid input, which was statistically significant. Conclusion In patients with septic shock, administering norepinephrine within one hour did not result in a difference in 28-day mortality rates but did reduce net fluid input and resuscitation fluid volume. Further research is needed to determine whether the very early use of vasopressors can improve outcomes.