血管紧张素 II 对血管扩张性休克的治疗
一项对 321 名患者的随机对照试验（RCT）显示，当血管扩张性休克患者对高剂量的传统血管加压药无反应时，血管紧张素 II 可以升高这部分患者的血压。这项临床试验效力不足以确定伴随功能性神经系统结局的生存改善。[101]Khanna A, English SW, Wang XS, et al. Angiotensin II for the treatment of vasodilatory shock. N Engl J Med. 2017 Aug 3;377(5):419-30.http://www.nejm.org/doi/full/10.1056/NEJMoa1704154http://www.ncbi.nlm.nih.gov/pubmed/28528561?tool=bestpractice.com
体外膜肺氧合 (ECMO)
当药物和手术难以治疗休克时，ECMO 可能通过提供机械性肺脏和循环支持而在心源性休克的处理中起一定的作用。[102]Schmidt M, Burrell A, Roberts L, et al. Predicting survival after ECMO for refractory cardiogenic shock: the survival after veno-arterial-ECMO (SAVE)-score. Eur Heart J. 2015 Sep 1;36(33):2246-56.http://eurheartj.oxfordjournals.org/content/36/33/2246.longhttp://www.ncbi.nlm.nih.gov/pubmed/26033984?tool=bestpractice.com[103]Ouweneel DM, Schotborgh JV, Limpens J, et al. Extracorporeal life support during cardiac arrest and cardiogenic shock: a systematic review and meta-analysis. Intensive Care Med. 2016 Dec;42(12):1922-34.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5106498/http://www.ncbi.nlm.nih.gov/pubmed/27647331?tool=bestpractice.com
血管加压素联合儿茶酚胺治疗分布性休克
在一项对RCTs进行的系统综述和荟萃分析中，与单用儿茶酚胺相比，在儿茶酚胺中添加血管加压素可显著降低分布性休克患者的房颤风险 (高质量的证据)。[104]McIntyre WF, Um KJ, Alhazzani W, et al. Association of vasopressin plus catecholamine vasopressors vs catecholamines alone with atrial fibrillation in patients with distributive shock: a systematic review and meta-analysis. JAMA. 2018 May 8;319(18):1889-1900.https://jamanetwork.com/journals/jama/fullarticle/2680546http://www.ncbi.nlm.nih.gov/pubmed/29801010?tool=bestpractice.com在此综述中纳入的研究罕有详细阐明血管加压素启用、滴定以及中和的方法。
左西孟旦
左西孟旦，一种正性肌力药物，通过提高心肌对钙的敏感性，增加心脏收缩力。低质量证据表明，与多巴酚丁胺相比，左西孟旦可降低心源性休克或低心输出量综合征患者的短期死亡率。[105]Schumann J, Henrich EC, Strobl H, et al. Inotropic agents and vasodilator strategies for the treatment of cardiogenic shock or low cardiac output syndrome. Cochrane Database Syst Rev. 2018 Jan 29;(1):CD009669.https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD009669.pub3/fullhttp://www.ncbi.nlm.nih.gov/pubmed/29376560?tool=bestpractice.com 在长期随访期间，左西孟旦与多巴酚丁胺相比，并未降低死亡率。[105]Schumann J, Henrich EC, Strobl H, et al. Inotropic agents and vasodilator strategies for the treatment of cardiogenic shock or low cardiac output syndrome. Cochrane Database Syst Rev. 2018 Jan 29;(1):CD009669.https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD009669.pub3/fullhttp://www.ncbi.nlm.nih.gov/pubmed/29376560?tool=bestpractice.com 在感染性休克患者中, 左西孟旦可增加心脏指数和左室射血分数，但与多巴酚丁胺相比，死亡率并未得以降低。[106]Bhattacharjee S, Soni KD, Maitra S, et al. Levosimendan does not provide mortality benefit over dobutamine in adult patients with septic shock: a meta-analysis of randomized controlled trials. J Clin Anesth. 2017 Jun;39:67-72.http://www.ncbi.nlm.nih.gov/pubmed/28494911?tool=bestpractice.com[107]Chang W, Xie JF, Xu JY, et al. Effect of levosimendan on mortality in severe sepsis and septic shock: a meta-analysis of randomised trials. BMJ Open. 2018 Mar 30;8(3):e019338.https://bmjopen.bmj.com/content/8/3/e019338.longhttp://www.ncbi.nlm.nih.gov/pubmed/29602841?tool=bestpractice.com 左西孟旦目前在美国未获批准使用。
多粘菌素 B 血液灌流
荟萃分析表明，多粘菌素-B 血液灌流是一种利用多粘菌素-B吸附滤芯在体外去除循环内毒素的技术，可以降低特定疾病严重程度亚组中严重败血症和感染性休克患者的死亡率。[108]Chang T, Tu YK, Lee CT, et al. Effects of polymyxin B hemoperfusion on mortality in patients with severe sepsis and septic shock: a systemic review, meta-analysis update, and disease severity subgroup meta-analysis. Crit Care Med. 2017 Aug;45(8):e858-64.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5515642/http://www.ncbi.nlm.nih.gov/pubmed/28445237?tool=bestpractice.com 然而，在随后的一项 RCT 中, 靶向多粘菌素 B 血液灌流并没有降低感染性休克 (高敏锐度，并且死亡风险高于先前试验的患者) 和内毒素水平升高患者的28天死亡率。[109]Dellinger RP, Bagshaw SM, Antonelli M, et al. Effect of targeted polymyxin B hemoperfusion on 28-day mortality in patients with septic shock and elevated endotoxin level: the EUPHRATES randomized clinical trial. JAMA. 2018 Oct 9;320(14):1455-63.http://www.ncbi.nlm.nih.gov/pubmed/30304428?tool=bestpractice.com
