Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany.
Crit Care Med. 2011 Jun;39(6):1335-42. doi: 10.1097/CCM.0b013e318212096a.
Hydroxyethyl starch 200 is associated with renal impairment in sepsis, but hydroxyethyl starch 130/0.4 and gelatin are considered to be less harmful. We hypothesized that fluid therapy with only crystalloids would decrease the incidence of acute kidney injury.
Prospective sequential comparison during intensive care unit stay.
Surgical intensive care unit.
Patients with severe sepsis.
Changes in standard fluid therapy, with predominantly 6% hydroxyethyl starch from January 2005 to June 2005, 4% gelatin from January 2006 to June 2006, and only crystalloids from September 2008 to June 2009.
Acute kidney injury was defined by the presence of at least one RIFLE class; 118 patients received hydroxyethyl starch, 87 patients received gelatin, 141 patients received only crystalloids. Baseline serum creatinine values were similar. Patients received median cumulative doses of 46 (interquartile range, 18-92) mL/kg hydroxyethyl starch and 43 (interquartile range, 18-76) mL/kg gelatin. Total median fluid amounts were 649 (interquartile range, 275-1098) mL/kg in the hydroxyethyl starch group, 525 (237-868) mL/kg in the gelatin group, and 355 (173-911) mL/kg in the crystalloid group. The difference was statistically significant for hydroxyethyl starch after adjustment for multiple testing. Mean daily fluid intake and fluid balance were higher on days 0 and 1 in the crystalloid group. Acute kidney injury occurred in 70% of patients receiving hydroxyethyl starch (adjusted p = .002) and in 68% of patients receiving gelatin (adjusted p = .025) vs. 47% patients receiving crystalloids. Need for renal replacement therapy tended to be higher in the hydroxyethyl starch group (34%; adjusted p = .086) and in the gelatin group (34%; adjusted p = .162) in comparison to the crystalloid group (20%). Intensive care unit and hospital mortality were similar in each group (hydroxyethyl starch: 35% and 43%; gelatin: 26% and 31%; crystalloids: 30% and 37%).
Fluid resuscitation with only crystalloids was equally effective, resulted in a more positive fluid balance only on the first 2 days, and was associated with a lesser incidence of acute kidney injury.
羟乙基淀粉 200 在脓毒症中与肾功能损害相关，但羟乙基淀粉 130/0.4 和明胶被认为危害较小。我们假设仅使用晶体液进行液体治疗会降低急性肾损伤的发生率。
在重症监护病房住院期间进行前瞻性序贯比较。
外科重症监护病房。
严重脓毒症患者。
标准液体治疗的变化，2005 年 1 月至 6 月期间主要使用 6%羟乙基淀粉，2006 年 1 月至 6 月期间使用 4%明胶，2008 年 9 月至 2009 年 6 月期间仅使用晶体液。
急性肾损伤的定义为至少存在一个 RIFLE 分级；118 例患者接受羟乙基淀粉，87 例患者接受明胶，141 例患者接受仅晶体液。基线血清肌酐值相似。患者接受的累积剂量中位数分别为羟乙基淀粉 46（四分位距，18-92）ml/kg 和明胶 43（四分位距，18-76）ml/kg。羟乙基淀粉组总液体量中位数为 649（四分位距，275-1098）ml/kg，明胶组为 525（237-868）ml/kg，晶体组为 355（173-911）ml/kg。羟乙基淀粉组在调整多次检验后差异具有统计学意义。晶体组在第 0 天和第 1 天的平均每日液体摄入量和液体平衡更高。接受羟乙基淀粉的患者中有 70%（调整后 p=0.002）和接受明胶的患者中有 68%（调整后 p=0.025）发生急性肾损伤，而接受晶体液的患者有 47%。羟乙基淀粉组（34%；调整后 p=0.086）和明胶组（34%；调整后 p=0.162）比晶体组（20%）更倾向于需要肾脏替代治疗。各组重症监护病房和医院死亡率相似（羟乙基淀粉：35%和 43%；明胶：26%和 31%；晶体液：30%和 37%）。
仅用晶体液复苏效果相当，仅在最初 2 天内产生更积极的液体平衡，且与急性肾损伤发生率降低相关。
