关于多巴胺的使用问题？

qsj2008

关于多巴胺的使用问题，在药物手册中或药典中使用时，只能静脉滴注，没有直接静注。但在我们麻醉界，椐我所知有不少医院麻醉科的医师在紧急地情况下都采用静注少量（20mg/支用生理盐水稀释成l20m，每次静注1~2 mg l）。效果没错，未发现任何并发症。不知这样是否妥当。敬请同行来讨论。

[ 本帖最后由 qsj2008 于 2008-11-7 23:22 编辑 ]

zhaoyuyi

药品名称 3-羟酪胺;儿茶酚乙胺;二羟基苯丙胺 ，多巴胺
英文名Dopamine
适应症
用于各种类型休克，包括中毒性休克、心原性休克、出血性休克、中枢性休克、非凡对伴有肾功能不全、心输出量降低、四周血管阻力增高而已补足血容量的病人有意义。
用量用法
将２０ｍｇ加入５％葡萄糖溶液２００～３００ｍｌ中静滴，开始每分钟２０滴左右（即每分钟滴入７５～１００μｇ）。以后根据血压情况，可加快速度或加大浓度。最大剂量：每分钟５００μｇ。
注重事项
1.大剂量时可使呼吸加速、心律失常，停药后即迅速消失。 2.使用前应补充血容量及纠正酸中毒。 3.静滴时，应观察血压、心率、尿量和一般状况。 4.有恶心、呕吐、头痛、中枢神经系统兴奋等不良反应。 5.多巴胺输注时不能外溢。 6.长期或大量输注时，亦可引起末梢缺血或坏疽。
药品规格 注射液：每支２０ｍｇ（２ｍｌ）。

atpxsh

（引用）最近的病例讨论中，我们反复提到多巴胺的使用是否合理。我过去也谈到，多巴胺在外科领域，已经没有什么使用价值。从个人的经验看，多巴胺的作用太广泛但不清楚，在提高后负荷时，对心肌刺激较大，心律失常太多，心肌氧耗增大。我个人是主张分别选用／合用，分别调节作用单一的药物。

从理论上看，在休克治疗中，去甲已经被证明效果优于多巴胺。在心衰方面，文献中很多关于多巴胺导致更坏结果的报告。至于最为得意的肾保护，也被证明是不存在的（Lancet. 2000 Dec 23-30;356(9248):2139-43）。

就大家经常遇到的休克而言，最近一篇文章，对欧洲 98 个ICU中，3,147名感染性和非感染性病人分析，表明用多巴胺者，ICU 死亡率，30天死亡率和住院死亡率，都比不用多巴胺高（见表）。

Does dopamine administration in shock influence outcome? Results of the Sepsis Occurrence in Acutely Ill Patients (SOAP) Study.

Sakr Y, Reinhart K, Vincent JL, Sprung CL, Moreno R, Ranieri VM, De Backer D, Payen D.
Department of Intensive Care, Erasme Hospital, Free University of Brussels, Belgium.
Crit Care Med. 2006 Mar;34(3):589-97.

OBJECTIVE: The optimal adrenergic support in shock is controversial. We investigated whether dopamine administration influences the outcome from shock. DESIGN: Cohort, multiple-center, observational study. SETTING: One hundred and ninety-eight European intensive care units. PATIENTS: All adult patients admitted to a participating intensive care unit between May 1 and May 15, 2002. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patients were followed up until death, until hospital discharge, or for 60 days. Shock was defined as hemodynamic compromise necessitating the administration of vasopressor catecholamines. Of 3,147 patients, 1,058 (33.6%) had shock at any time; 462 (14.7%) had septic shock. The intensive care unit mortality rate for shock was 38.3% and 47.4% for septic shock. Of patients in shock, 375 (35.4%) received dopamine (dopamine group) and 683 (64.6%) never received dopamine. Age, gender, Simplified Acute Physiology Score II, and Sequential Organ Failure Assessment score were comparable between the two groups. The dopamine group had higher intensive care unit (42.9% vs. 35.7%, p=.02) and hospital (49.9% vs. 41.7%, p=.01) mortality rates. A Kaplan-Meier survival curve showed diminished 30 day-survival in the dopamine group (log rank=4.6, p=.032). In a multivariate analysis with intensive care unit outcome as the dependent factor, age, cancer, medical admissions, higher mean Sequential Organ Failure Assessment score, higher mean fluid balance, and dopamine administration were independent risk factors for intensive care unit mortality in patients with shock. CONCLUSIONS: This observational study suggests that dopamine administration may be associated with increased mortality rates in shock. There is a need for a prospective study comparing dopamine with other catecholamines in the management of circulatory shock.

同期的 Critical Care Medicine 中的编者按指出，大家好像对多巴胺的偏爱好像是社区医院的传统和对去甲的“惧怕”，并没有什么依据。“一点β ，一点 ɑ ，兴许管用”。（也就是我的万金油之说）。There is no rational evidence to support this, but one may argue that among community hospital physicians, there is a certain “fear” of norepinephrine and the belief that dopamine, “a little bit β and a little bit ɑ, as inotrope or vasopressor, may do the job.” 同时，该编者按再次强调了多巴胺对肾没有保护作用，反而增加肾氧耗。There is evidence that dopamine may increase renal oxygen consumption and may therefore jeopardize renal oxygen supply/demand balance. There is also ample evidence that the so-called renal dopamine does not change mortality, risk of renal failure, or need for extracorporeal renal replacement therapy ([24]). The evidence-based guidelines published in 2004 in this journal do not support the use of dopamine as renal protection or renal salvage agent ([27]).

随后一篇由危重医学高手 Pinsky 共同作者的读书会中，指出一个尖锐的问题：多巴胺是不是无形的杀手？Could dopamine be a silent killer? （http://ccforum.com.foyer.swmed.edu/content/11/1/302#B11）他们分析了以上研究的长处和不足，并指出去甲早已被证明比多巴胺治疗低血压有效，并说明正在进行的多巴胺和去甲治疗休克的临床试验（http://www.clinicaltrials.gov/ct/show/NCT00314704）。

虽然这一研究有其局限性，但至少说明，多巴胺已经不是什么万应药。之所以有人提出疑问，进行对比研究，正是表明其副作用正在被人们注意。我已经十多年没有在主流外科麻醉和危重医学领域见到多巴胺了。

希望大家提高警惕！

aopeminem

去甲大家还是用的保守了