Daily Lowest Hemoglobin and Risk of Organ Dysfunctions in Critically Ill Patients.
Daily Lowest Hemoglobin and Risk of Organ Dysfunctions in Critically Ill Patients.
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DOI：
10.1097/ccm.0000000000002288
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发表时间：
2017-05
影响因子：
8.8
通讯作者：
Weavind LM
中科院分区：
文献类型：
--
作者：
Hemauer SJ;Kingeter AJ;Han X;Shotwell MS;Pandharipande PP;Weavind LM
确定重症患者血红蛋白水平与个体器官功能障碍每日风险之间的关系。我们对前瞻性收集的内科和外科ICU呼吸衰竭或休克患者的数据进行了事后分析。收集基线人口统计学数据以及ICU和医院内的详细数据，包括每日最低血红蛋白，直至住院第30天。我们每天评估患者的脑功能障碍[谵妄，使用ICU混乱评估方法（CAM-ICU）]，肾和呼吸功能障碍[使用顺序肾和呼吸器官衰竭评估（SOFA评分）]以及ICU死亡率。采用多变量回归分析，调整年龄、APACHE II评分、Charlson合并症指数、卒中风险、ICU天数、ICU类型、败血症和当前器官功能障碍状态，评估给定日期最低血红蛋白与次日器官功能障碍之间的关系。一项敏感性分析进一步调整了我们的一部分患者的每日输血和液体平衡。我们入组了821例患者，中位（四分位距，IQR）年龄为61（51，71）岁，APACHE II评分为25（19，31），血红蛋白水平为10.0（9.0，11.1）g/dl。没有证据表明每日最低血红蛋白与脑功能障碍（谵妄p=0.69）、肾功能障碍（p=0.30）或ICU死亡率（p=0.95）之间存在关联。某一天的最低血红蛋白与第二天的呼吸SOFA评分显著相关;血红蛋白单位每增加一个，第二天呼吸SOFA评分恶化的几率降低36%（OR 0.64，95% CI：0.53，0.77，p < 0.001）。敏感性分析包括每日输血和液体平衡（在518例患者的子集中），并没有定性地改变任何这些关联。在这项针对ICU患者的研究中，较低的血红蛋白与第二天呼吸功能障碍评分恶化的可能性较高相关。没有证据表明血红蛋白与脑或肾功能障碍或ICU死亡率之间存在关联。在推荐限制性输血指南的任何改变之前，必须在更大的前瞻性研究中研究本假设生成研究中观察到的贫血对器官功能障碍的可能差异影响。
To determine the association between hemoglobin levels and the daily risk of individual organ dysfunctions in critically ill patients. We performed a post-hoc analysis of prospectively collected data in medical and surgical ICU patients admitted with respiratory failure or shock. Baseline demographic data, and detailed in-ICU and hospital data, including daily lowest hemoglobin, were collected up to hospital day 30. We assessed patients daily for brain dysfunction [delirium, using Confusion Assessment Method for ICU (CAM-ICU)], for renal and respiratory dysfunction [using the ordinal renal and respiratory Sequential Organ Failure Assessment (SOFA score)], and for ICU mortality. Associations between the lowest hemoglobin on a given day and organ dysfunctions the following day were assessed using multivariable regressions, adjusting for age, APACHE II score, Charlson comorbidity index, Framingham stroke risk profile, ICU day, ICU type, sepsis, and current organ dysfunction status. A sensitivity analysis further adjusted for daily transfusions and fluid balance in a subset of our patients. We enrolled 821 patients with a median (interquartile range, IQR) age of 61 (51, 71) years, APACHE II score of 25 (19, 31), and hemoglobin level of 10.0 (9.0, 11.1) g/dl. There was no evidence of an association between lowest daily hemoglobin and brain dysfunction (p=0.69 for delirium), renal dysfunction (p=0.30) or ICU mortality (p=0.95). The lowest hemoglobin on a given day was significantly associated with the respiratory SOFA score the following day; for each increasing hemoglobin unit, the odds of worsened respiratory SOFA score the following day were decreased by 36% (OR 0.64, 95% CI: 0.53, 0.77, p < 0.001). The sensitivity analysis including daily transfusions and fluid balance (in a subset of 518 patients) did not qualitatively change any of these associations. In this study in ICU patients, lower hemoglobin was associated with a higher probability of worsening respiratory dysfunction scores the following day. There was no evidence of association between hemoglobin and brain or renal dysfunction, or ICU mortality. The possible differential effects of anemia on organ dysfunctions seen in this hypothesis generating study will have to be studied in a larger prospective study before any alterations to present restrictive transfusion guidelines can be recommended.