医学交流课件：血管加压素与危重病

1、 Case report The picture of AVP AVP-R and antagonists Related agents Clinical use XX, M, 60yrs 服 DDV 300ml 24小时 转入我院 ICU 被发现时昏迷,大汗, 瞳孔针尖样 入当地医院气管插管 MV 后洗胃 4h shock DOPA 转入时 20ug/kg/min 24小时应用阿托品45mg XX, F, 31yrs 足月经阴分娩后阴道出血 分娩后1.5小时 CPR CPR5 分钟成功 分娩后3小时 子宫全切术 分娩后5小时转入ICU: 七窍出血 持续低血压7小时 NE2-4, DOPA10

2、-20, AVP 2- 8U/h 入 ICU7小时 FFP 3200ml 冷沉淀20U RBC32U 血小板1人份 Why? When? Who ? Dose? 合成: 视上核和室旁核 储存: 垂体后叶 代谢: 肝脏和肾脏 半衰期10-35min 受体受体分布分布 作用作用 V1a 血管 血管平滑肌,肝脏, 肾小球出球小动 脉 收缩血管, 促进肝糖元 分解,增加血小板聚集, 增加肾小球灌注压, GFR 增加 V2 肾脏 肾集合管促进水重吸收, 抗利尿 V3(V 1b) 垂体 垂体刺激 ACTH 释放 V2R Antagonist (Tolvaptan托伐 普坦,商品名-苏麦卡, satavap

3、tan, lixivaptan) V1a-V2R Antagonist (conivaptan) 肝硬化腹水, 心衰, SIADH 加压素(vasopressin) 血管加压素 精氨酸 加压素(AVP) 抗利尿激素(ADH) 抗利尿 作用/血管平滑肌收缩作用 特利加压素(terlipresssin, t-GLVP) 一 种新型人工合成血管加压素 垂体后叶素垂体后叶素 含催产素和加压素 收缩子宫 /抗利尿/升高血压 猪牛羊脑神经垂体中 提取 鞣酸加压素(长效尿崩停) 去氨加压素(弥凝) 抗利尿作用/血管 加压作用比 约为加压素的1200- 3000倍 中枢性尿崩症 CDI CPR Septic

4、shock Because the effects of AVP have not been shown to differ from those of E in CA, 1 dose of AVP 40 units IV/IO may replace either the 1st or 2nd dose of E in the treatment of CA (Class IIb, LOE A). 加压素40u 1次 IV/IO 可用于替代 CPR 时首剂或第二剂副肾素 AVP improves vital organ blood flow during closed-chest cardi

5、opulmonary resuscitation in pigs Circulation. 1995;91:215221 AVP 0.03 u/min can be added to NE with intent of either raising MAP or decreasing NE dosage (UG). 在 NE 应用的基础上, 感染性休克病人 可加用 AVP 0.03u/min 以进一步提 高 MAP 或减少 NE 用量 Low dose AVP is not recommended as the single initial vasopressor for treatment

6、of sepsis-induced hypotension 不推荐小剂量加压素作为脓毒症性低血 压单独的初始升压药物 AVP doses 0.03-0.04 u/min should be reserved for salvage therapy (failure to achieve adequate MAP with other vasopressor agents) (UG). 高剂量 AVP(0.03-0.04u/min) 可 用于脓毒性休克病人其他升压药物效果 不满意的补救性治疗 relative vasopressin deficiency AVP concentrations a

7、re elevated in early S. Shock, but decrease to normal range in the majority of patients between 24 and 48 hrs as shock continues . In the presence of hypotension, vasopressin would be expected to be elevated The VASST trial an RCT: comparing NE to NE + AVP 0.03 U/min no difference in outcome An a pr

8、iori defined subgroup analysis demonstrated that survival among patients receiving 15 g/ min NE at the time of randomization was better with the addition of AVP; N Engl J Med 2008; 358:877887 Higher doses of vasopressin have been associated with cardiac, digital, and splanchnic ischemia and Should be reserved for situations where alternative vasopressors have failed Crit Care Med 2003;