Patterns and Outcomes Associated With Timeliness of Initial Crystalloid Resuscitation in a Prospective Sepsis and Septic Shock Cohort
Patterns and Outcomes Associated With Timeliness of Initial Crystalloid Resuscitation in a Prospective Sepsis and Septic Shock Cohort
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DOI：
10.1097/ccm.0000000000002574
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发表时间：
2017-10-01
影响因子：
8.8
通讯作者：
D'Angelo, John K.
中科院分区：
文献类型：
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作者：
Leisman, Daniel E.;Goldman, Chananya;D'Angelo, John K.
目的：本研究的目的是：1)评估脓毒症和感染性休克患者的早期晶体复苏模式；2)确定初始晶体复苏时间与住院死亡率、机械通气、ICU使用率和住院时间之间的关系。设计：连续抽样观察队列。地点：9家三级医院和社区医院超过1.5年。患者：纳入前瞻性质量改进数据库的成年败血症和感染性休克患者纳入标准：疑似或确诊感染，大于或等于两个全身炎症反应标准，大于或等于一个器官功能障碍标准。干预：主要暴露在脓毒症确诊后30分钟或更短、31-120分钟或超过120分钟内晶体启动。测量和主要结果：我们确定了11,182名患者。急诊科患者(贝塔，-141min；CI，-159to-125；P<；0.001)、基线低血压(贝塔，-39min；CI、.48%至48%。32；p<；0.001)、发烧、尿路或皮肤/软组织感染源。心力衰竭(贝塔，20分钟；CI，14-25；P<；0.001)和肾功能衰竭(贝塔，16分钟；CI，10-22；P<；0.001)启动较慢。5,336名患者(48%)在30分钟或更短的时间内开始结晶，而31-120分钟和超过120分钟的患者分别为2,388名(21%)和3,458名(31%)。接受30分钟内输液的患者死亡率最低(949例，17.8%)，而31-120分钟(446例，18.7%)和超过120分钟(846例，24.5%)的患者死亡率最低。与超过120min相比，调整后的死亡优势比在30min及以下分别为0.76(CI，0.64~0.9；p=0.002)和0.76(CI，0.62~0.92；p=0.004)。当持续评估时，开始前每小时死亡率增加1.09(CI，1.03-1.16；p=0.002)。我们在机械通风、ICU使用率和住院时间方面观察到类似的模式。我们没有观察到启动时间与基线心力衰竭、肾功能衰竭、低血压、急性肾损伤、气体交换改变或急诊科(VS住院患者)病死率之间的显著交互作用。结论：在合并心力衰竭和肾功能衰竭、无发热或低血压的住院患者中，晶体启动时间明显较晚。更早的晶体形成与死亡率的降低有关。合并症和严重程度并没有改变这种效果。
Objectives: The objectives of this study were to 1) assess patterns of early crystalloid resuscitation provided to sepsis and septic shock patients at initial presentation and 2) determine the association between time to initial crystalloid resuscitation with hospital mortality, mechanical ventilation, ICU utilization, and length of stay.Design: Consecutive-sample observational cohort.Setting: Nine tertiary and community hospitals over 1.5 years.Patients: Adult sepsis and septic shock patients captured in a prospective quality improvement database inclusion criteria: suspected or confirmed infection, greater than or equal to two systemic inflammatory response criteria, greater than or equal to one organ-dysfunction criteria.Interventions: The primary exposure was crystalloid initiation within 30 minutes or lesser, 31-120 minutes, or more than 120 minutes from sepsis identification.Measurements and Main Results: We identified 11,182 patients. Crystalloid initiation was faster for emergency department patients (beta, -141 min; CI, -159 to -125; p < 0.001), baseline hypotension (beta, -39 min; CI,. 48 to. 32; p < 0.001), fever, urinary or skin/soft-tissue source of infection. Initiation was slower with heart failure (beta, 20 min; CI, 14-25; p < 0.001), and renal failure (beta, 16 min; CI, 10-22; p < 0.001). Five thousand three hundred thirty-six patients (48%) had crystalloid initiated in 30 minutes or lesser versus 2,388 (21%) in 31-120 minutes, and 3,458 (31%) in more than 120 minutes. The patients receiving fluids within 30 minutes had lowest mortality (949 [17.8%]) versus 31-120 minutes (446 [18.7%]) and more than 120 minutes (846 [24.5%]). Compared with more than 120 minutes, the adjusted odds ratio for mortality was 0.76 (CI, 0.64-0.90; p = 0.002) for 30 minutes or lesser and 0.76 (CI, 0.62-0.92; p = 0.004) for 31-120 minutes. When assessed continuously, mortality odds increased by 1.09 with each hour to initiation (CI, 1.03-1.16; p = 0.002). We observed similar patterns for mechanical ventilation, ICU utilization, and length of stay. We did not observe significant interaction for mortality risk between initiation time and baseline heart failure, renal failure, hypotension, acute kidney injury, altered gas exchange, or emergency department (vs inpatient) presentation.Conclusions: Crystalloid was initiated significantly later with comorbid heart failure and renal failure, with absence of fever or hypotension, and in inpatient-presenting sepsis. Earlier crystalloid initiation was associated with decreased mortality. Comorbidities and severity did not modify this effect.