外科学课件：外科感染.ppt

* * * * * * When patients with septic and cardiogenic shock are maintained at the same mean arterial blood pressure with vasopressors, it is noted that cardiogenic shock patients maintain elevated vasopressin levels while patients with septic shock over time have lower levels that approach baseline. In addition, prospective, randomized, blinded studies have demonstrated the potential for low-dose vasopressin to decrease or eliminate requirements of traditional pressors. However, as a pure vasopressor/vasopressin would be expected to decrease stroke volume and cardiac output as traditional vasopressors are replaced. This may be problematic, particularly in patients with significant decrease in ejection fraction and low baseline cardiac outputs. * Although vasopressin has been demonstrated in some studies to improve renal function, there are other studies that raise concern about preservation of splanchnic perfusion. Vasopressin should not be considered a replacement for norepinephrine or dopamine as a first-line agent in septic shock. However, it may be considered in refractory shock despite high-dose conventional vasopressors or when high vasopressor requirements continue for 48 hours or longer. If used, it should be administered at very low doses, not to exceed .04 units/min in adults. Higher doses may be associated with coronary or mesenteric ischemia. * A significant contractility decrease may occur in some patients with septic shock. When cardiac output is being measured (either invasively or noninvasively) and a low cardiac output is present despite adequate fluid resuscitation, the consideration of adding dobutamine to raise cardiac output to a normal range is appropriate. It is important when this is done to continue to titrate vasopressors to maintain a mean arterial pressure of ? 65 mm Hg. * The utilization of stress dose (“low-dose”) steroids is recommended for the treatment of patients with severe sepsis who continue to require significant