急性肺损伤中两种液体管理策略的比较

Comparison of two fluid-management strategies in acute lung injury.

作者信息

Wiedemann Herbert P, Wheeler Arthur P, Bernard Gordon R, Thompson B Taylor, Hayden Douglas, deBoisblanc Ben, Connors Alfred F, Hite R Duncan, Harabin Andrea L

机构信息

Department of Pulmonary, Allergy, and Critical Care Medicine, Cleveland Clinic, 9500 Euclid Ave., Desk A-90, Cleveland, OH 44195, USA.

出版信息

N Engl J Med. 2006 Jun 15;354(24):2564-75. doi: 10.1056/NEJMoa062200. Epub 2006 May 21.

DOI:10.1056/NEJMoa062200

PMID:16714767

Abstract

BACKGROUND

Optimal fluid management in patients with acute lung injury is unknown. Diuresis or fluid restriction may improve lung function but could jeopardize extrapulmonary-organ perfusion.

METHODS

In a randomized study, we compared a conservative and a liberal strategy of fluid management using explicit protocols applied for seven days in 1000 patients with acute lung injury. The primary end point was death at 60 days. Secondary end points included the number of ventilator-free days and organ-failure-free days and measures of lung physiology.

RESULTS

The rate of death at 60 days was 25.5 percent in the conservative-strategy group and 28.4 percent in the liberal-strategy group (P=0.30; 95 percent confidence interval for the difference, -2.6 to 8.4 percent). The mean (+/-SE) cumulative fluid balance during the first seven days was -136+/-491 ml in the conservative-strategy group and 6992+/-502 ml in the liberal-strategy group (P<0.001). As compared with the liberal strategy, the conservative strategy improved the oxygenation index ([mean airway pressure x the ratio of the fraction of inspired oxygen to the partial pressure of arterial oxygen]x100) and the lung injury score and increased the number of ventilator-free days (14.6+/-0.5 vs. 12.1+/-0.5, P<0.001) and days not spent in the intensive care unit (13.4+/-0.4 vs. 11.2+/-0.4, P<0.001) during the first 28 days but did not increase the incidence or prevalence of shock during the study or the use of dialysis during the first 60 days (10 percent vs. 14 percent, P=0.06).

CONCLUSIONS

Although there was no significant difference in the primary outcome of 60-day mortality, the conservative strategy of fluid management improved lung function and shortened the duration of mechanical ventilation and intensive care without increasing nonpulmonary-organ failures. These results support the use of a conservative strategy of fluid management in patients with acute lung injury. (ClinicalTrials.gov number, NCT00281268 [ClinicalTrials.gov].).

摘要

背景

急性肺损伤患者的最佳液体管理方案尚不清楚。利尿或液体限制可能改善肺功能，但可能危及肺外器官灌注。

方法

在一项随机研究中，我们采用明确的方案，对1000例急性肺损伤患者进行了为期7天的保守和宽松液体管理策略比较。主要终点是60天时的死亡情况。次要终点包括无呼吸机天数、无器官衰竭天数以及肺生理学指标。

结果

保守策略组60天时的死亡率为25.5%，宽松策略组为28.4%（P = 0.30；差异的95%置信区间为 -2.6%至8.4%）。保守策略组前7天的平均（±SE）累积液体平衡为 -136 ± 491 ml，宽松策略组为6992 ± 502 ml（P < 0.001）。与宽松策略相比，保守策略改善了氧合指数（[平均气道压×吸入氧分数与动脉血氧分压之比]×100）和肺损伤评分，并增加了前28天的无呼吸机天数（14.6 ± 0.5天对12.1 ± 0.5天，P < 0.001）以及未在重症监护病房的天数（13.4 ± 0.4天对11.2 ± 0.4天，P < 0.001），但在研究期间未增加休克的发生率或患病率，在60天内也未增加透析的使用（10%对14%，P = 0.06）。