Alsous F, Khamiees M, DeGirolamo A, Amoateng-Adjepong Y, Manthous C A
Division of Pulmonary and Critical Care, Bridgeport Hospital and Yale University School of Medicine, Bridgeport, CT 06610, USA.
Chest. 2000 Jun;117(6):1749-54. doi: 10.1378/chest.117.6.1749.
We hypothesized that patients with septic shock who achieve negative fluid balance (< or =-500 mL) on any day in the first 3 days of management are more likely to survive than those who do not.
Retrospective chart review.
Thirty-six patients admitted with the diagnosis of septic shock.
Twelve-bed medical ICU of a 300-bed community teaching hospital.
Medical records of 36 patients admitted to our medical ICU over a 21-month period were examined. Patients with septic shock who required dialysis prior to hospitalization were not included. A number of demographic and physiologic variables were extracted from the medical records. Admission APACHE (acute physiology and chronic health evaluation) II and daily sequential organ failure assessment (SOFA) scores were computed from the extracted data. Variables were compared between survivors and nonsurvivors and in patients who did vs those who did not achieve negative (< or = 500 mL) fluid balance in > or = 1 day of the first 3 days of management. Survival risk ratios (RRs) were used as the measure of association between negative fluid balance and survival. RRs were adjusted for age, APACHE II scores, SOFA scores on the first and third days, and the need for mechanical ventilation, by stratified analyses.
Patients ranged in age from 16 to 85 years with a mean (+/- SE) age of 67.4 +/- 3.3 years. The mean admission APACHE II score was 25.4 +/- 1.4, and the day 1 SOFA score was 9.0 +/- 0.8. Twenty patients did not survive; nonsurvivors had higher mean APACHE II scores than survivors (29.8 vs 20.4, respectively) and higher first day SOFA scores than survivors (10.8 vs 6.9, respectively), and they were more likely to require vasopressors and mechanical ventilation compared to patients who survived. Whereas all 11 patients who achieved a negative balance of > 500 mL on > or = 1 of the first 3 days of treatment survived, only 5 of 25 patient who failed to achieve a negative fluid balance of > 500 mL by the third day of treatment survived (RR, 5.0; 95% CI, 2.3 to 10.9; p = 0.00001). At least 1 day of net negative fluid balance in the first 3 days of treatment strongly predicted survival across the strata of age, APACHE II scores, first- and third-day SOFA scores, the need for mechanical ventilation, and creatinine levels measured at admission.
These results suggest that at least 1 day of negative fluid balance (< or = -500 mL) achieved by the third day of treatment may be a good independent predictor of survival in patients with septic shock. These findings suggest the hypothesis "that negative fluid balance achieved in any of the first 3 days of septic shock portends a good prognosis," for a larger prospective cohort study.
我们假设在脓毒性休克患者治疗的头3天中，任何一天实现负液体平衡（≤ -500 ml）的患者比未实现的患者更有可能存活。
回顾性病历审查。
36例诊断为脓毒性休克的患者。
一家拥有300张床位的社区教学医院的12张床位的内科重症监护病房。
检查了21个月期间入住我们内科重症监护病房的36例患者的病历。排除住院前需要透析的脓毒性休克患者。从病历中提取了一些人口统计学和生理学变量。根据提取的数据计算入院时急性生理与慢性健康状况评估（APACHE）II评分和每日序贯器官衰竭评估（SOFA）评分。比较幸存者和非幸存者之间以及在治疗的头3天中≥1天实现负（≤ 500 ml）液体平衡的患者与未实现的患者之间的变量。生存风险比（RRs）用作负液体平衡与生存之间关联的衡量指标。通过分层分析对RRs进行年龄、APACHE II评分、第一天和第三天的SOFA评分以及机械通气需求的校正。
患者年龄在16至85岁之间，平均（± SE）年龄为67.4 ± 3.3岁。平均入院APACHE II评分为25.4 ± 1.4，第1天SOFA评分为9.0 ± 0.8。20例患者未存活；非幸存者的平均APACHE II评分高于幸存者（分别为29.8和20.4），第一天的SOFA评分高于幸存者（分别为10.8和6.9），与存活患者相比，他们更有可能需要血管升压药和机械通气。在治疗的头3天中≥1天实现> 500 ml负平衡的所有11例患者均存活，而在治疗第3天未能实现> 500 ml负液体平衡的25例患者中仅5例存活（RR，5.0；95% CI，2.3至10.9；p = 0.00001）。治疗头3天中至少1天的净负液体平衡强烈预测了不同年龄、APACHE II评分、第一天和第三天的SOFA评分、机械通气需求以及入院时测量的肌酐水平分层患者的生存情况。
这些结果表明，治疗第3天实现至少1天的负液体平衡（≤ -500 ml）可能是脓毒性休克患者生存的良好独立预测指标。这些发现为一项更大规模的前瞻性队列研究提出了“脓毒性休克头3天中任何一天实现负液体平衡预示着良好预后”这一假设。
