血管加压素和危重病优质课件

血管加压素和危重病血管加压素和危重病Contents

Case

report

The

picture

of

AVP

AVP-R

and

antagonists

Related

agents

Clinical

use

ContentsCasereport2Case

1XX,

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/min24小时应用阿托品45mgCase1XX,M,60yrs3Case

report

Casereport4Case

2XX,

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,

DOPA10-20,

AVP

2-8U/h

入ICU7小时FFP

3200ml冷沉淀20U

RBC32U血小板1人份Case2XX,F,31yrs5问题Why?When?Who

?Dose?问题Why?6AVP合成

释放

代谢合成:视上核和室旁核储存:垂体后叶代谢:肝脏和肾脏半衰期10-35minAVP合成释放代谢合成:视上核和室旁核7

受体分布作用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(V1b)垂体垂体刺激ACTH释放受体分布作用V1a血管平滑肌,肝脏,肾小球出球小动脉收缩8加压素受体拮抗剂

V2R

Antagonist

(Tolvaptan托伐普坦,商品名-苏麦卡,

satavaptan,

lixivaptan)

V1a-V2RAntagonist

(conivaptan)

肝硬化腹水,心衰,

SIADH加压素受体拮抗剂V2RAntagonist(Tolv9Related

agents

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

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Relatedagents加压素(vasopressi10Related

agents

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Relatedagents鞣酸加压素(长效尿崩停)11Clinicaluse.

中枢性尿崩症CDI

CPR

Septic

shockClinicaluse.中枢性尿崩症CDI12AVPandCPRBecausetheeffectsofAVPhavenotbeenshowntodifferfromthoseofEinCA,1doseofAVP40unitsIV/IOmayreplaceeitherthe1stor2nddoseofEinthetreatmentofCA(ClassIIb,LOEA).

加压素40u

1次IV/IO可用于替代CPR时首剂或第二剂副肾素AVPandCPRBecausetheeffect13The

introduction

of

AVP

AVPimprovesvitalorganbloodflowduringclosed-chestcardiopulmonaryresuscitationinpigs

Circulation.1995;91:215–221TheintroductionofAVPAVPim14AVPandshockAVP0.03u/mincanbeaddedtoNEwithintentofeitherraisingMAPordecreasingNEdosage(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AVPandshockAVP0.03u/minca15AVPandshockLowdoseAVPisnotrecommendedasthesingleinitialvasopressorfortreatmentofsepsis-inducedhypotension

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AVPandshockLowdoseAVPisn16AVPandshockAVPdoses>0.03-0.04u/minshouldbereservedforsalvagetherapy(failuretoachieveadequateMAPwithothervasopressoragents)(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AVPandshockAVPdoses>0.03-17RationalerelativevasopressindeficiencyAVPconcentrationsareelevatedinearlyS.

Shock,butdecreasetonormalrangeinthemajorityofpatientsbetween24and48hrsasshockcontinues.Inthepresenceofhypotension,vasopressinwouldbeexpectedtobeelevatedRationalerelativevasopressin18Timing

TheVASSTtrialanRCT:

comparingNEtoNE+AVP0.03U/minnodifferenceinoutcomeAnaprioridefinedsubgroupanalysisdemonstratedthatsurvivalamongpatientsreceiving<15μg/minNEatthetimeofrandomizationwasbetterwiththeadditionofAVP;NEnglJMed2008;358:877–887TimingTheVASSTtrial19Adverse

effectsHigherdosesofvasopressinhavebeenassociatedwithcardiac,digital,andsplanchnicischemiaandShouldbereservedforsituationswherealternativevasopressorshavefailed

CritCareMed2003;31:1394–1398

AdverseeffectsHigherdosesof20Children?AVPlevelsarereducedinadultswithsepticshock

AVPlevelsseemtovaryextensivelyinchildren

no

recommandationChildren?AVPlevelsarereduce21ThanksforyouratentionThanksforyouratention22血管加压素和危重病血管加压素和危重病Contents

Case

report

The

picture

of

AVP

AVP-R

and

antagonists

Related

agents

Clinical

use

ContentsCasereport24Case

1XX,

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/min24小时应用阿托品45mgCase1XX,M,60yrs25Case

report

Casereport26Case

2XX,

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,

DOPA10-20,

AVP

2-8U/h

入ICU7小时FFP

3200ml冷沉淀20U

RBC32U血小板1人份Case2XX,F,31yrs27问题Why?When?Who

?Dose?问题Why?28AVP合成

释放

代谢合成:视上核和室旁核储存:垂体后叶代谢:肝脏和肾脏半衰期10-35minAVP合成释放代谢合成:视上核和室旁核29

受体分布作用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(V1b)垂体垂体刺激ACTH释放受体分布作用V1a血管平滑肌,肝脏,肾小球出球小动脉收缩30加压素受体拮抗剂

V2R

Antagonist

(Tolvaptan托伐普坦,商品名-苏麦卡,

satavaptan,

lixivaptan)

V1a-V2RAntagonist

(conivaptan)

肝硬化腹水,心衰,

SIADH加压素受体拮抗剂V2RAntagonist(Tolv31Related

agents

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

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Relatedagents加压素(vasopressi32Related

agents

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Relatedagents鞣酸加压素(长效尿崩停)33Clinicaluse.

中枢性尿崩症CDI

CPR

Septic

shockClinicaluse.中枢性尿崩症CDI34AVPandCPRBecausetheeffectsofAVPhavenotbeenshowntodifferfromthoseofEinCA,1doseofAVP40unitsIV/IOmayreplaceeitherthe1stor2nddoseofEinthetreatmentofCA(ClassIIb,LOEA).

加压素40u

1次IV/IO可用于替代CPR时首剂或第二剂副肾素AVPandCPRBecausetheeffect35The

introduction

of

AVP

AVPimprovesvitalorganbloodflowduringclosed-chestcardiopulmonaryresuscitationinpigs

Circulation.1995;91:215–221TheintroductionofAVPAVPim36AVPandshockAVP0.03u/mincanbeaddedtoNEwithintentofeitherraisingMAPordecreasingNEdosage(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AVPandshockAVP0.03u/minca37AVPandshockLowdoseAVPisnotrecommendedasthesingleinitialvasopressorfortreatmentofsepsis-inducedhypotension

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AVPandshockLowdoseAVPisn38AVPandshockAVPdoses>0.03-0.04u/minshouldbereservedforsalvagetherapy(failuretoachieveadequateMAPwithothervasopressoragents)(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AVPandshockAVPdoses>0.03-39RationalerelativevasopressindeficiencyAVPconcentrationsareelevatedinearlyS.

Shock,butdecreasetonormalrangeinthemajorityofpatientsbetween24and48hrsasshockcontinues.Inthepresenceofhypotension,vasopressinwouldbeexpectedtobeelevatedRationalerelativevasopressin40Timing

TheVASSTtrialanRCT:

comparingNEtoNE+AV