JAMA Network Open:早期脓毒症所致低血压的外周升压药应用

Abstract

Importance: Evidence supporting the safety of infusing vasopressors through peripheral intravenous catheters (peripheral vasopressors) is largely derived from single-center studies, limiting generalizability.目前支持通过外周静脉导管输注升压药（即外周升压药）安全性的证据主要来自单中心研究，这限制了其结果的普遍适用性。

Objective: To evaluate factors associated with vasopressor route selection and assess safety and clinical outcomes of peripheral vasopressor administration in early sepsis resuscitation.评估与升压药给药途径选择相关的因素，并考察早期脓毒症复苏中外周升压药使用的安全性和临床结局。

Design, setting, and participants: This prospective cohort study is a secondary analysis of the Crystalloid Liberal vs Early Vasopressors in Sepsis (CLOVERS) trial conducted in 60 US hospitals from March 2018 to February 2022. Patients in CLOVERS who received vasopressors within 24 hours of enrollment and did not have central venous access at enrollment were included. Data were analyzed from January 2023 to June 2025.本研究是一项前瞻性队列研究，为2018年3月至2022年2月期间在美国60家医院开展的“晶体液自由 vs 早期升压药治疗脓毒症”（CLOVERS）试验的二次分析。纳入标准为在入组24小时内接受升压药治疗且在入组时没有建立中心静脉通路的患者。数据分析时间为2023年1月至2025年6月。

Exposure: Route of vasopressor initiation (central or peripheral).升压药起始使用的途径（经外周静脉或中心静脉）。

Main outcomes and measures: The primary analysis evaluated the route of vasopressor initiation, while the secondary analysis assessed continuation of peripheral vasopressors beyond 6 hours. Univariable and multivariable analyses of factors associated with vasopressor route were conducted, as was a multivariable analysis to evaluate the association of route with outcomes, including 90-day mortality. Descriptive statistics were used to summarize 28-day peripheral vasopressor and central venous catheter (CVC) complications.主要分析评估升压药起始使用的途径；次要分析评估升压药在外周持续使用超过6小时的情况。对影响升压药使用途径的因素进行单变量和多变量分析，并对使用不同途径与临床结局（包括90天死亡率）之间的关系进行多变量回归分析。采用描述性统计分析总结28天内发生外周升压药相关并发症及中心静脉导管（CVC）相关并发症的发生率。

Results: Of 1563 patients in CLOVERS, 582 (37.2%) received vasopressors and met study inclusion criteria. Included patients had a median (IQR) age of 63 (52-72) years, and 267 (45.9%) were female, 96 (16.5%) were African American, 416 (71.5%) were White, and 70 (12.0%) were another race or had unreported race. Vasopressors were initiated via peripheral catheter in 490 patients (84.2%) and via central venous access in 92 patients (15.8%). Study site was the only factor independently associated with route of initiation (median odds ratio, 3.48; 95% CI, 1.57-5.38). In adjusted analyses, peripheral vs central initiation was associated with statistically comparable 90-day mortality (128 participants [26.1%] vs 34 participants [37.0%]; adjusted odds ratio, 0.67; 95% CI, 0.39-1.16). Peripheral vasopressors were continued beyond 6 hours in 333 of 490 patients (68.0%). Peripheral vasopressor complications were rare and low-grade (3 of 490 patients [0.6%]), with no cases of ulceration or tissue injury. In contrast, there were 14 complications from CVC placement occurring in 12 of 322 patients (3.7%) who had CVCs placed in the first 72 hours.在CLOVERS试验的1563例患者中，有582例（37.2%）接受了升压药治疗并符合本研究纳入标准。这些患者的年龄中位数为63岁（四分位距[IQR]，52–72），其中女性267人（45.9%），非裔美国人96人（16.5%），白人416人（71.5%），另有70人（12.0%）为其他种族或未报告种族。490例患者（84.2%）通过外周静脉开始升压药治疗，92例患者（15.8%）通过中心静脉通路开始治疗。研究地点是唯一与升压药起始途径独立相关的因素（中位数优势比[OR]为3.48；95%置信区间[CI]，1.57–5.38）。在校正分析中，外周起始升压药与中心静脉起始相比，其90天死亡率无统计学差异（分别为128人[26.1%] vs 34人[37.0%]；校正后OR=0.67；95%CI，0.39–1.16）。在490例经外周起始升压药的患者中，有333例（68.0%）在6小时后继续使用外周升压药。外周升压药相关并发症罕见且程度轻微（490例中仅3例[0.6%]），未见溃疡或组织损伤病例。相比之下，在前72小时内置入CVC的322例患者中，有12例（3.7%）发生了14起CVC相关并发症。

Conclusions and relevance: In this prospective cohort study of the CLOVERS trial, peripheral administration of vasopressors was common and was associated with low complication rates. These findings support the safety and feasibility of short-term peripheral vasopressor use in early sepsis resuscitation.在这项基于CLOVERS试验的前瞻性队列研究中，外周途径给予升压药较为常见，且并发症发生率低。这些发现支持在早期脓毒症复苏中短期使用外周升压药的安全性与可行性。