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Place des inotropes en réanimation

Inotropic support in the intensive care unit

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Réanimation

Résumé

La balance bénéfice/risque des agents inotropes est parfois difficile à appréhender. La plupart des agents inotropes positifs augmentent le calcium intracellulaire (avec le risque d’induire des arythmies et de l’apoptose notamment) et la consommation en oxygène dumyocarde. Pour autant, certaines situations cliniques nécessitent encore l’utilisation de ces molécules. La dobutamine reste probablement la molécule de choix dans la plupart de ces situations. De mécanisme d’action original (augmentation de la sensibilité des fibres au calcium) et probablement moins consommateur d’énergie que les catécholamines, le lévosimendan semble être prometteur. Ses indications restent à mieux définir et la molécule n’est pas disponible en France. Au cours du choc cardiogénique et des intoxications médicamenteuses par cardiotropes, la dobutamine reste le traitement inotrope de première intention (comme l’isoprénaline pour les intoxications par bétabloquants). Les doses élevées d’insuline (au moins 1 UI/kg/h) sont intéressantes dans ces intoxications à visée inotrope. En cas de cardiopathie de stress, l’utilisation de la dobutamine doit être prudente si elle est nécessaire, et en cas d’aggravation sous traitement, il faudra à l’inverse utiliser un bétabloquant, remplir et utiliser un vasopresseur. Lors du sepsis, la dobutamine doit probablement n’être utilisée que: 1) en cas de dysfonction myocardique avérée; 2) avec signes de dysoxie tissulaire. L’utilisation de bétabloquants dans ce contexte vient d’être testée et semble prometteuse mais nécessite des études cliniques complémentaires. Quelle que soit l’indication des inotropes, le bénéfice doit être souvent réévalué, et le traitement arrêté dès que la situation clinique le permet, voire avant, en cas d’aggravation.

Abstract

The benefit-risk ratio of inotropic agents is debated with drawbacks, mainly in relation to increased intracellular calcium, possibly responsible for arrhythmias and apoptosis, and increased oxygen consumption. Thus, clinical scenarios request caution when administering an inotropic agent. Dobutamine is the best first-line choice. Indications of levosimendan, a calcium fiber sensitizer still not marketed in France, remain controversial. In cardiogenic shock and cardiotoxicant poisoning, dobutamine (or isoprenaline for beta-blockers) is also the first-line agent, while high-dose insulin presents interesting effects. In contrast, in Takotsubo cardiomyopathy, dobutamine administration may be at risk: if dobutamine worsens the situation, betablockade should be preferred, concomitantly with fluids and vasopressors. In sepsis, dobutamine should be only used in case of septic cardiomyopathy or evidence for dysoxia. Beta-blockade, only tested in septic shock, seems interesting and requires further investigations. Whatever the indication is, the benefit of inotropic agent infusion should be repeatedly evaluated and stopped as soon as possible if sideeffects are evidenced.

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Authors and Affiliations

  1. Pôle de réanimation, CHRU de Lille, Lille, France

    L. Satre Buisson, J. Poissy, P. Girardie, D. Mathieu & R. Favory

  2. Département universitaire de thérapeutique, CHRU de Lille, Lille, France

    R. Favory

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  1. L. Satre Buisson
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  2. J. Poissy
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  3. P. Girardie
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  4. D. Mathieu
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  5. R. Favory
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Correspondence to R. Favory.

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Satre Buisson, L., Poissy, J., Girardie, P. et al. Place des inotropes en réanimation. Réanimation 23, 167–175 (2014). https://doi.org/10.1007/s13546-014-0860-6

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