晶体平衡液与生理盐水用于危重成年患者的比较
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Balanced Crystalloids versus Saline in Critically Ill Adults
背景与目的
晶体平衡液和生理盐水均可用于危重患者的静脉输液，但目前尚不清楚哪种方案能取得更好的临床效果。
方 法
我们在一个学术中心的五个重症监护病房进行了一项实用性、集群随机、多交叉试验，根据患者入院所在单元进行随机分组，将15802名患者随机分配输注生理盐水（0.9%氯化钠）或晶体平衡液（乳酸林格溶液或复方电解质溶液）。主要结局是30天内肾脏发生严重不良事件的综合——任何原因引起死亡、新肾替代治疗或持续性肾功能不全（定义为肌酐水平升高至基线水平的200%以上）——在出院时或出院30天内进行检测（以先发生者为准）。
结 果
与生理盐水组7860例患者中发生1211例（15.4%）相比，晶体平衡液组7942例患者中有1139例（14.3%）出现严重的肾脏不良事件（MOR 0.91；95%CI 0.84-0.99；COR 0.90；95%CI 0.82-0.99；P=0.04）。晶体平衡液组30天住院死亡率为10.3%，生理盐水组为11.1%（P=0.06），新肾替代治疗的发生率分别为2.5%和2.9%（P=0.08），持续性肾功能不全的发生率分别为6.4%和6.6%（P=0.60）。
结 论
在危重成年患者中，与生理盐水相比，静脉输注晶体平衡液可降低任何原因引起死亡、新肾替代治疗或持续性肾功能不全所导致的综合结局的发生率。
原始文献摘要
Semler MW, Self WH, Wanderer JP, et al. Balanced Crystalloids versus Saline in Critically Ill Adults.[J].N Engl J Med. 2019 March 01; 378(9): 829–839. doi:10.1056/NEJMoa1711584.
BACKGROUND—Both balanced crystalloids and saline are used for intravenous fluid administration in critically ill adults, but it is not known which results in better clinical outcomes.
METHODS—In a pragmatic, cluster-randomized, multiple-crossover trial conducted in five intensive care units at an academic center, we assigned 15,802 adults to receive saline (0.9% sodium chloride) or balanced crystalloids (lactated Ringer’s solution or Plasma-Lyte A) according to the randomization of the unit to which they were admitted. The primary outcome was a major adverse kidney event within 30 days — a composite of death from any cause, new renalreplacement therapy, or persistent renal dysfunction (defined as an elevation of the creatinine level to ≥200% of baseline) — all censored at hospital discharge or 30 days, whichever occurred first.
RESULTS—Among the 7942 patients in the balanced-crystalloids group, 1139 (14.3%) had a major adverse kidney event, as compared with 1211 of 7860 patients (15.4%) in the saline group (marginal odds ratio, 0.91; 95% confidence interval [CI], 0.84 to 0.99; conditional odds ratio, 0.90; 95% CI, 0.82 to 0.99; P = 0.04). In-hospital mortality at 30 days was 10.3% in the balancedcrystalloids group and 11.1% in the saline group (P = 0.06). The incidence of new renalreplacement therapy was 2.5% and 2.9%, respectively (P = 0.08), and the incidence of persistent renal dysfunction was 6.4% and 6.6%, respectively (P = 0.60).
CONCLUSIONS—Among critically ill adults, the use of balanced crystalloids for intravenous fluid administration resulted in a lower rate of the composite outcome of death from any cause, new renal-replacement therapy, or persistent renal dysfunction than the use of saline.
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贵州医科大学高鸿教授课题组
翻译：冯玉蓉 编辑：冯玉蓉 审校：王贵龙