重症监护病房（ICU）脓毒症患者急性肾衰竭（ARF）中液体状态与其管理之间的关系：一项前瞻性分析。

Relationship between fluid status and its management on acute renal failure (ARF) in intensive care unit (ICU) patients with sepsis: a prospective analysis.

作者信息

Van Biesen Wim, Yegenaga Itir, Vanholder Raymond, Verbeke Francis, Hoste Erik, Colardyn Francis, Lameire Norbert

机构信息

Renal Division, University Hospital, Ghent-Belgium.

出版信息

J Nephrol. 2005 Jan-Feb;18(1):54-60.

PMID:15772923

Abstract

BACKGROUND

Sepsis carries a high morbidity and mortality, further enhanced by acute renal failure (ARF). Although fluid loading can prevent ARF in dehydrated patients, this approach could be risky in septic patients, since it can deteriorate oxygenation. This study evaluates the relationship between fluid status and management and ARF development in septic patients.

METHODS AND PATIENTS

Patients admitted to the ICU between 1 January 2001 and 31 December 2001 were included if serum creatinine (Cr) was <2 mg% on admission, and if they developed sepsis. ARF was determined as a doubling of serum Cr, an increase of serum Cr >2 mg%, or oliguria <500 ml/24 hr.

RESULTS

257 out of 2442 patients, admitted to the intensive care unit (ICU), developed sepsis, 29 developed ARF, 13 needed a renal replacement. ARF vs. non-ARF patients were older (65.2 +/- 13.3 vs. 55.1 +/- 17.4, p=0.002), had a higher central venous pressure (CVP) at day 1 (9.6 +/- 4.3 vs. 5.2 +/- 3.6 mmHg, p<0.001), and at day 2 (7.1 +/- 5.1 vs. 5.1 +/- 4.0 mmHg, p=0.03), a higher colloid fluid loading for the first 3 days (2037 +/- 1681 vs. 1116 +/- 1220 mL, p<0.03), a higher serum Cr (1.25 +/- 0.39 vs. 0.96 +/- 0.33 mg/dL, p=0.009) and an increase vs. a decrease in serum Cr during the first 24 hr (+0.30 +/- 0.58 vs. -0.31 +/- 0.45 mg/dL, p=0.02), a lower diuresis (1347 +/- 649 vs. 1849 +/- 916 mL, p=0.005). There was no difference in APACHE II scores (19.2 +/- 7.2 vs. 17.2 +/- 6.6, p=0.1), or MAP (64.5 +/- 12.4 vs. 67.9 +/- 12.4, p=0.18). The fraction of inspired oxygen (FiO2) need in the ARF group increased from 40.4 +/- 11.5 to 65.6 +/- 24.2% from day 1 to day 2 (p=0.04), where it remained unchanged in the non-ARF group. The use of diuretics was higher in the ARF group (21/29 vs. 43/228, p=0.001).

CONCLUSION

Septic patients developing ARF have an elevated CVP at day 1 of sepsis, indicating cardiodepression or intrarenal causes for hypoperfusion. These patients develop ARF despite further fluid loading. Respiratory function deteriorated in patients with ARF. Persistent fluid challenges should be avoided if they do not lead to an improvement in renal function, or if oxygenation deteriorates.

摘要

背景

脓毒症具有较高的发病率和死亡率，急性肾衰竭（ARF）会进一步加剧这种情况。尽管补液可预防脱水患者发生ARF，但这种方法在脓毒症患者中可能存在风险，因为它会使氧合恶化。本研究评估脓毒症患者的液体状态与管理以及ARF发生之间的关系。

方法与患者

纳入2001年1月1日至2001年12月31日期间入住重症监护病房（ICU）的患者，要求入院时血清肌酐（Cr）<2mg%且发生脓毒症。ARF的判定标准为血清Cr翻倍、血清Cr升高>2mg%或尿量<500ml/24小时。

结果

2442名入住重症监护病房（ICU）的患者中有257名发生脓毒症，其中29名发生ARF，13名需要进行肾脏替代治疗。发生ARF的患者与未发生ARF的患者相比，年龄更大（65.2±13.3岁对55.1±17.4岁，p = 0.002），第1天中心静脉压（CVP）更高（9.6±4.3mmHg对5.2±3.6mmHg，p<0.001），第2天也更高（7.1±5.1mmHg对5.1±4.0mmHg，p = 0.03），前3天胶体液补液量更多（2037±1681ml对1116±1220ml，p<0.03），血清Cr更高（1.25±0.39mg/dL对0.96±0.33mg/dL，p = 0.009），且第1个24小时内血清Cr升高而非降低（+0.30±0.58mg/dL对 -0.31±0.45mg/dL，p = 0.02），尿量更低（1347±649ml对1849±916ml，p = 0.005）。急性生理与慢性健康状况评分系统（APACHE II）评分（19.2±7.2对17.2±6.6，p = 0.1）或平均动脉压（MAP）（64.5±12.4mmHg对67.9±12.4mmHg，p = 0.18）无差异。ARF组从第1天到第2天所需的吸入氧分数（FiO2）从40.4±11.5%增加到65.6±24.2%（p = 0.04），而在未发生ARF的组中保持不变。ARF组利尿剂的使用比例更高（21/29对43/228，p = 0.001）。