Utilisation de la noradrénaline dans le traitement du choc septique

Abstract

The effects of noradrenaline were studied in 16 patients, with either a hyperkinetic septic shock syndrome or a septic shock resistant to dobutamine treatment. The study aimed to restore normal tissue perfusion pressure, assessed by a return to normal of urine output or blood pressure. An optimal left ventricular filling pressure, estimated by the pulmonary capillary wedge pressure, was obtained for each patient using a Swan-Ganz catheter. The administration of 10.6 ± 0.5 μg · kg −1 · min −1 dobutamine (starting dose : 6 μg · kg −1 · min −1) was started when the cardiac index (CI) was less than 3.31 · min −1 · m −2 after vascular filling with plasma expanders. Patients became eligible for noradrenaline treatment when they fulfilled the following conditions : arterial systolic pressure (Pa sys) ⩽ 90 mmHg ; systemic vascular resistances ⩽ 600 dyn · s · cm −5 ; CI ⩾ 3.5 l · min −1 · m −2 ; persistent oliguria (< 30 ml · h −1). This drug was given at a constant rate with a starting dose of 0.5 μg · kg −1 · min −1, increased every 10 min by 0.3 to 0.6 μg · kg −1 · min −1 according to the effects on Pa sys and hourly urine output. Eight patients received noradrenaline alone ; the efficient dose was 0.9 ± 0.2 μg · kg −1 · min −1, and it was used for a mean 5.1 ± 1 days. CI increased in those patients who were given both noradrenaline and dobutamine. Thirteen out of the 16 patients had a dramatic increase in urine output ; only three patients remained oliguric. There were no effects on serum creatinine concentration, anion gap, intrapulmonary shunt and oxygen consumption. Sixty nine percent of the patients survived the episode of septic shock and 50 % were discharged from hospital. The use of noradrenaline with or without dobutamine in the treatment of septic shock is recommended.