Association Between the Choice of IV Crystalloid and In-Hospital Mortality Among Critically Ill Adults With Sepsis
Association Between the Choice of IV Crystalloid and In-Hospital Mortality Among Critically Ill Adults With Sepsis
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DOI：
10.1097/ccm.0000000000000305
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发表时间：
2014-07-01
影响因子：
8.8
通讯作者：
Lindenauer, Peter K.
中科院分区：
文献类型：
--
作者：
Raghunathan, Karthik;Shaw, Andrew;Lindenauer, Peter K.
目的：等渗盐水是 ICU 中最常用的晶体液，但最近的证据表明，乳酸林格氏液等平衡液体可能更好。我们研究了脓毒症危重成人复苏期间晶体液选择与院内死亡率之间的关系。设计：一项回顾性队列研究，对象为脓毒症入院、未接受任何外科手术、入院第 2 天在 ICU 接受治疗的患者。我们使用倾向评分匹配来控制混杂因素，并比较了平衡液体与非平衡液体复苏后的以下结果：院内死亡率、有或没有透析的急性肾功能衰竭以及住院情况。以及 ICU 住院时间。我们还估计了平衡液体摄入比例增加与院内死亡率之间的剂量反应关系。背景：2005 年 11 月至 2010 年 12 月期间属于 Premier Healthcare 联盟成员的 360 家美国医院。患者：截至入院第 2 天，共有 53,448 名脓毒症患者在 ICU 接受血管加压药和晶体液治疗，其中 3,396 名患者 (6.4%) 接受了干预措施：无。测量和主要结果：使用平衡液体治疗的患者更年轻，患心脏或慢性肾功能衰竭的可能性较小，但他们更有可能接受机械通气、侵入性监测、胶体、类固醇和更大的晶体体积（中位 7 升与 5 升）。在倾向匹配队列中的 6,730 名患者中，接受平衡液体与较低的院内死亡率相关（19.6% vs 22.8%；相对风险，0.86；95% CI，0.78，0.94）。接受较大比例平衡液体的患者死亡率逐渐降低。急性肾衰竭（有或没有透析）的患病率或住院和 ICU 住院时间没有显着差异。结论：在患有脓毒症的危重成人中，平衡液体复苏与较低的院内死亡率风险相关。如果在随机试验中得到证实，这一发现可能会对公共卫生产生重大影响，因为晶体复苏在脓毒症中几乎普遍存在。
Objective: Isotonic saline is the most commonly used crystalloid in the ICU, but recent evidence suggests that balanced fluids like Lactated Ringer's solution may be preferable. We examined the association between choice of crystalloids and in-hospital mortality during the resuscitation of critically ill adults with sepsis.Design: A retrospective cohort study of patients admitted with sepsis, not undergoing any surgical procedures, and treated in an ICU by hospital day 2. We used propensity score matching to control for confounding and compared the following outcomes after resuscitation with balanced versus with no-balanced fluids: in-hospital mortality, acute renal failure with and without dialysis, and hospital and ICU lengths of stay. We also estimated the dose-response relationship between receipt of increasing proportions of balanced fluids and in-hospital mortality.Setting: Three hundred sixty U.S. hospitals that were members of the Premier Healthcare alliance between November 2005 and December 2010.Patients: A total of 53,448 patients with sepsis, treated with vasopressors and crystalloids in an ICU by hospital day 2 including 3,396 (6.4%) that received balanced fluids.Interventions: None.Measurements and Main Results: Patients treated with balanced fluids were younger and less likely to have heart or chronic renal failure, but they were more likely to receive mechanical ventilation, invasive monitoring, colloids, steroids, and larger crystalloid volumes (median 7 vs 5 L). Among 6,730 patients in a propensity-matched cohort, receipt of balanced fluids was associated with lower in-hospital mortality (19.6% vs 22.8%; relative risk, 0.86; 95% CI, 0.78, 0.94). Mortality was progressively lower among patients receiving larger proportions of balanced fluids. There were no significant differences in the prevalence of acute renal failure (with and without dialysis) or in-hospital and ICU lengths of stay.Conclusions: Among critically ill adults with sepsis, resuscitation with balanced fluids was associated with a lower risk of in-hospital mortality. If confirmed in randomized trials, this finding could have significant public health implications, as crystalloid resuscitation is nearly universal in sepsis.