#46
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Ñïàñèáî çà ññûëêè, [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] - õîðîøàÿ êíèæêà. Ïî ïîâîäó ðîñòà ÄÇËÊ, òàê ÷èñòûé äîïìèí äî 20 ìû íèêîãäà íå èñïîëüçóåì, êîìáèíèðóåì ñ íèòðî, äîáóòàìèíîì, àäðåíàëèíîì, íîðàäðåíàëèíîì, ñèìäàêñîì. Ïîýòîìó ýêñïåðèìåíò ìîæåò áûòü íå ÷èñòûì. Íàñêîëüêî òîíêî ïðîâîäèëîñü èññëåäîâàíèå 1985 ãîäà ( [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ]) ñóäèòü íåëüçÿ, ïîëíûé òåêñò îíëàéí íå äîñòóïåí. Òàê Âû - çà äîáóòàìèí? ß íå ïðîòèâ. Îñîáåííî ïðè ëåãî÷íîé àðòåðèàëüíîé ãèïåðòåíçèè. Òîæå ÷àñòî ñòàâèòñÿ ïåðâûì. Õîòÿ íåêîòîðûå ïàöèåíòû îòêàçûâàþòñÿ ìî÷èòüñÿ íà ñðåäíèõ äîçàõ äîáóòàìèíà, è ñîãëàøàþòñÿ íà ýêâèâàëåíòíûõ äîçàõ äîïàìèíà.  îáùåì òî, íå ïðåäìåò äëÿ ñïîðà. Âîïðîñ èçíà÷àëüíî áûë î íîðàäðåíàëèíå. À âîò íà "È ñîâåðøåííî íåçà÷åì óáèâàòüñÿ" ÿ îáèæóñü è óéäó.
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#47
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 ïðèâåäåííûõ èññëåäîâàíèÿõ ðîñò ÄÇËÀ ïðè èñïîëüçîâàíèè äîïàìèíà îòìå÷àëñÿ íà äîçàõ ãîðàçäî ìåíüøèõ, ÷åì 20 ìêã/êã/ìèí. Ïîäîáíûå èññëåäîâàíèÿ îòíþäü íå åäèíè÷íûå, ïîýòîìó åñòü ëè ñìûñë îñïàðèâàòü óòâåðæäåíèå î ïîâûøåíèè ÄÇËÀ ïð èñïîëüçîâàíèè äîïàìèíà?
Öèòàòà:
Âàøå ïðàâî, îáèäà è åå ïðè÷èíû åñòü øòóêà ëè÷íàÿ. È åùå, òðóäíî óñëåäèòü çà ñêà÷êàìè ìûñëè îò ÄÇËÀ äî òåìïà ìî÷åîòäåëåíèÿ íà òîì èëè èíîì èíîòðîïå. Äàâàéòå êàê íèáóäü ïîñëåäîâàòåëüíî. |
#48
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Åñëè ñìîòðåòü íà öåëîãî áîëüíîãî, òî ÄÇËÀ è òåìï ìî÷åîòäåëåíèÿ íå òàê óæ è äàëåêî. Ñïðàâèòüñÿ ñ îñòðîé ëåâîæåëóäî÷êîâîé íåäîñòàòî÷íîñòüþ ïîìîãàþò êàê äîïìèí, òàê è äîáóòàìèí, â òîì ÷èñëå è çà ñ÷åò óëó÷øåíèÿ äèóðåçà. Èç [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] : ñ.232 - "first line treatment - intravenous dopamine 3-5mkg/kg/min., uptitrated to achieve sys.BP 90-100..Other authorities prefer norepinephrine or epinephrine to dopamine as the pressor of choice in cardiogenic shock".
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#49
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Òàê è äî ÷åãî ìû äîãîâîðèëèñü? Ñìåøàëèñü â êó÷ó êîíè, ëþäè...  ïðèâåäåííîé Âàìè êíèãå òåêñò íà÷èíàåòñÿ ñëîâàìè
Öèòàòà:
Öèòàòà:
Ïðî äîïàìèí è ïî÷êè òåìà îòäåëüíàÿ, äëèííàÿ, è óæå îáñóæäàâøàÿñÿ. |
#50
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Íå íàõîæó ÿ ýòèõ âñå-òàêè äàííûõ çíà÷èòåëüíîãî êîëè÷åñòâà, âòîðîé äåíü óæå. Âû èìååòå ââèäó (the rate of death at 28 days was significantly higher among patients with cardiogenic shock who were treated with dopamine than among those with cardiogenic shock who were treated with norepinephrine (P=0.03) èç "Comparison of Dopamine and Norepinephrine in the Treatment of Shock", íà êîòîðóþ ññûëàëèñü â äàííîì ôîðóìå? Õî÷ó åùå.
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#51
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Äà ýòî. È íà èñòèíó íå ïðåòåíäóþ, îñîçíàâàÿ âñå îãðàíè÷åíèÿ èññëåäîâàíèÿ. È íå çàñòàâëÿþ Âàñ ïîëüçîâàòüñÿ èñêëþ÷èòåëüíî íîðàäðåíàëèíîì âìåñòî äîïàìèíà. Õîòåòü åùå - òàêæå Âàøå ïðàâî. Ïîêà ÷òî åñòü, èçâèíèòå. Íàéäåòå ñàìè - ïîäåëèòåñü, áóäåì áëàãîäàðíû.
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#52
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îê...
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#53
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Âîò ÷òî ïèøåò "current"Dopamine is an endogenous catecholamine with qualitatively different effects at varying doses. At low doses (< 3 mcg/kg/min), it predominantly stimulates dopaminergic receptors that dilate various arterial beds, the most important being the renal vasculature. Although used frequently in low doses to improve renal perfusion, there is scant evidence to support the clinical usefulness of this strategy. Intermediate doses of 3–6 mcg/kg/min cause 1-receptor stimulation and enhanced myocardial contractility. Further increases in dosage lead to predominant -receptor stimulation (peripheral vasoconstriction) in addition to continued 1 stimulation and tachycardia. Dopamine increases cardiac output, and its combination of cardiac stimulation and peripheral vasoconstriction may be beneficial as initial treatment of hypotensive patients in cardiogenic shock.
Dobutamine is a synthetic sympathomimetic agent that differs from dopamine in two important ways: It does not cause renal vasodilatation, and it has a much stronger 2 (arteriolar vasodilatory) effect. The vasodilatory effect may be deleterious in hypotensive patients because a further drop in blood pressure may occur. On the other hand, many patients with cardiogenic shock experience excessive vasoconstriction with a resultant elevation in afterload (SVR) as a result of either the natural sympathetic discharge or the treatment with inotropic agents, such as dopamine, that also have prominent vasoconstrictor effects. In such patients, the combination of cardiac stimulation and decreased afterload with dobutamine may improve cardiac output without a loss of arterial pressure. Other agents that are occasionally used include isoproterenol and norepinephrine. Isoproterenol is also a synthetic sympathomimetic agent. It has very strong chronotropic and inotropic effects, resulting in a disproportionate increase in oxygen consumption and ischemia. It is therefore not generally recommended for cardiogenic shock except occasionally for patients with bradyarrhythmias. Norepinephrine has even stronger and 1 effects than dopamine and may be beneficial when a patient continues to be hypotensive despite large doses of dopamine (more than 20 mcg/kg/min). Because of the intense peripheral vasoconstriction that occurs, perfusion of other vascular beds such as the kidney, extremities, and mesentery may be compromised. Therefore, norepinephrine should not be used for any extended time unless plans are made for definitive treatment. Êàê ïî ìíå ïðàâèëüíî áûëî óòâåðæäåíèå ïðè ïåðåòÿãèâàíèè êàíàòîâ ïðè èñïîëüçîâàíèè äîáóòàìèíà ñ íîðàäðåíàëèíîì(äîáóòàìèíîì - ðàñøèðÿåì, íîðýïèíåôðèíîì - ñóæàåì). Ïðàâèëüíûé âûáîð èíîòðîïîâ è âàçîïðåññîðîâ ïî-ìîåìó ìîæíî ñäåëàòü òîëüêî çíàÿ öèôðû äàâëåíèå äàííîãî êîíêðåòíîãî áîëüíîãî. |
#54
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Òàê â ó÷åáíèêàõ ïî îáùåé àíåñòåçèîëîãèè ïèøóò.
Ê ïðîáëåìå êàíàòîâ, ÷òî Âû ñêàæåòå î ïðèìåíåíèè áåòà-áëîêàòîðîâ íà ôîíå ñèìïàòîìèìåòèêîâ? Íå âñå òàê ïðîñòî. |
#55
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Íó ñìîòðÿ íà ôîíå êàêèõ ìèìåòèêîâ. Íî, ÷åñòíî, íèêîãäà ïðè øîêàõ áåòà-áëîêàòîðû íå ââîäèë, ò.ê. â îñíîâíîì èìååì äåëî ñ ñåïòè÷åñêèìè øîêàìè. È â ïðîâîäèìîì âûøå èññëåäîâàíèè êàê ìíå êàæåòñÿ ñðàâíèâàëè èìåííî àëüôà-ìèìåòè÷åñêèé ýôôåêò íîðýïèíåôðèíà è âûñîêèõ äîç äîïàìèíà èìåííî êàê âàçîïðåññîðîâ, à íå èíîòðîïîâ. È ìåííî ïîòîìó ÷òî íîðýïèíåôðèí îáëàäàåò ìåíüøèì áåòà ýôôåêòîì â ëþáûõ äîçàõ îí íàâåðíîå ïðè øîêàõ ïðåäïî÷òèòåëüíåå. Âîîáùåì ÷òî ÿ âûíåñ èç ýòîãî èññëåäîâàíèÿ, ÷òî åñëè áîëüíîìó íàäî "ñòèìóëüíóòü " ñåðäöå è ïðèïîäíÿòü ÀÄ - äîïàìèí, åñëè äàâëåíèå íèæå ïëèíòóñà èëè ñðåäíèõ äîç äîïàìèíà íåõâàòàåò òî ëó÷øå ïåðåêëþ÷èòñÿ íà íîðýïèíåôðèí. À ÷òî íåîáõîäèìî â äàííîé ñèòóàöèè äàííîìó áîëüíîìó ìîæíî ñêàçàòü òîëüêî èç åãî ãåìîäèíàìèêè íà äàííûé ìîìåíò. Åñëè íàì íàäî "óòèõîìèðèòü" ñåðäöå èëè íå äàòü åìó ðàçîãíàòüñÿ ïðè íîðìàëüíîé ÔÂ, íî íàäî "ñîáðàòü" ñîñóäû è ïîäíÿòü äèàñòîëè÷åñêîå ÀÄ, òàê ìîæíî è áëîêàòîðû ñ íîðýïèíåôðèíîì ïîïðîáîâàòü.
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#56
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Öèòàòà:
Êàê íà÷àëî òèòðîâàíèÿ íåîáõîäèìîé äîçû íîðàäðåíàëèíà - 0,19ìêã/êã/ìèí, äîçà òåîðåòè÷åñêè âîçìîæíî è ïðèåìëåìà (íî óæ íå ýêâèïîòåíöèàëüíà), íî íå óâåðåí, ÷òî êëèíè÷åñêè ïðèìåíèìà, êîãäà â áîëüøèíñòâå ñëó÷àåâ ìû íå ìîæåò òî÷íî çíàòü ìàññó ïàöèåíòà â íàøèõ óñëîâèÿõ. Âñå-òàêè ÷àùå èíôóçèÿ íîðàäðåíàëèíà ñòàðòóåò ñ áîëåå "êðóãëûõ" áîëüøèõ öèôð - 0,2-0,3ìêã/êã/ìèí . Ïîïàëîñü íà ðóññêîì: [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] îäíîãî èç ãëàâíûõ "ñðàâíèòåëåé" íîðàäðåíàëèíà ñ äîïàìèíîì Claude Martin â ìýðèè ýòîãî ãîäà |
#57
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Öèòàòà:
Âîò èõ îòâåòû: Lee emphasizes the importance of reperfusion therapy in patients with cardiogenic shock. Percutaneous angioplasty was attempted in most of the 161 patients who were in shock as a result of acute myocardial infarction. However, in contrast to Lee's statement, the need for vasopressor agents in these patients was seldom transient, since in our trial, it lasted for a mean (±SD) duration of 3±5 days. As De Santis et al. mentioned, the use of intraaortic counterpulsation is often recommended, even though its effect on the outcome is still controversial, but we did not collect information on the use of intraaortic balloon pumps. Altogether, the patients in the trial were treated according to international recommendations, and there is no evidence that there was an imbalance between the two groups with respect to other therapies. [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] |