Department of Intensive Care, Austin Hospital, Melbourne, Australia.
Crit Care Med. 2011 Nov;39(11):2419-24. doi: 10.1097/CCM.0b013e31822571e5.
To determine the biochemical effects of restricting the use of chloride-rich intravenous fluids in critically ill patients.
Prospective, open-label, before-and-after study.
University-affiliated intensive care unit.
A cohort of 828 consecutive patients admitted over 6 months from February 2008 and cohort of 816 consecutive patients admitted over 6 months from February 2009.
We collected biochemical and fluid use data during standard practice without clinician awareness. After a 6-month period of education and preparation, we restricted the use of chloride-rich fluids (0.9% saline [Baxter, Sydney, Australia], Gelofusine [BBraun, Melsungen, Germany], and Albumex 4 [CSL Bioplasma, Melbourne, Australia]) in the intensive care unit and made them available only on specific intensive care unit specialist prescription.
Saline prescription decreased from 2411 L in the control group to 52 L in the intervention group (p < .001), Gelofusine from 538 to 0 L (p < .001), and Albumex 4 from 269 to 80 L (p < .001). As expected, Hartmann's lactated solution prescription increased from 469 to 3205 L (p < .001), Plasma-Lyte from 65 to 160 L (p < .05), and chloride-poor Albumex 20 from 87 to 268 L (p < .001). After intervention, the incidence of severe metabolic acidosis (standard base excess <-5 mEq/L) decreased from 9.1% to 6.0% (p < .001) and severe acidemia (pH <7.3) from 6.0% to 4.9% (p < .001). However, the intervention also led to significantly greater incidence of severe metabolic alkalosis (standard base excess >5 mEq/L) and alkalemia (pH >7.5) with an increase from 25.4% to 32.8% and 10.5% to 14.7%, respectively (p < .001). The time-weighted mean chloride level decreased from 104.9 ± 4.9 to 102.5 ± 4.6 mmol/L (p < .001), whereas the time-weighted mean standard base excess increased from 0.5 ± 4.5 to 1.8 ± 4.7 mmol/L (p < .001), mean bicarbonate from 25.3 ± 4.0 to 26.4 ± 4.1 mmol/L (p < .001) and mean pH from 7.40 ± 0.06 to 7.42 ± 0.06 (p < .001). Overall fluid costs decreased from $15,077 (U.S.) to $3,915.
In a tertiary intensive care unit in Australia, restricting the use of chloride-rich fluids significantly affected electrolyte and acid-base status. The choice of fluids significantly modulates acid-base status in critically ill patients.
确定限制危重症患者使用富含氯的静脉输液的生化影响。
前瞻性、开放标签、前后研究。
大学附属医院的重症监护病房。
2008 年 2 月连续 6 个月入院的 828 例队列患者和 2009 年 2 月连续 6 个月入院的 816 例队列患者。
我们在没有临床医生意识的情况下收集了标准实践中的生化和液体使用数据。经过 6 个月的教育和准备，我们限制了富含氯的液体（0.9%生理盐水[Baxter，悉尼，澳大利亚]、Gelofusine[BBraun，Melsungen，德国]和 Albumex 4[CSL Bioplasma，墨尔本，澳大利亚]）在重症监护病房的使用，并仅在特定的重症监护病房专家处方时提供。
生理盐水处方从对照组的 2411 升减少到干预组的 52 升（p <.001），Gelofusine 从 538 升减少到 0 升（p <.001），Albumex 4 从 269 升减少到 80 升（p <.001）。如预期的那样，Hartmann's 乳酸盐溶液处方从 469 升增加到 3205 升（p <.001），Plasma-Lyte 从 65 升增加到 160 升（p <.05），并且富含氯的 Albumex 20 从 87 升增加到 268 升（p <.001）。干预后，严重代谢性酸中毒（标准基础过剩<-5 mEq/L）的发生率从 9.1%降至 6.0%（p <.001），严重酸中毒（pH <7.3）的发生率从 6.0%降至 4.9%（p <.001）。然而，干预也导致严重代谢性碱中毒（标准基础过剩>5 mEq/L）和碱血症（pH >7.5）的发生率显著增加，分别从 25.4%增加到 32.8%和从 10.5%增加到 14.7%（p <.001）。时间加权平均氯水平从 104.9 ± 4.9 降至 102.5 ± 4.6 mmol/L（p <.001），而时间加权平均标准基础过剩从 0.5 ± 4.5 增加到 1.8 ± 4.7 mmol/L（p <.001），平均碳酸氢盐从 25.3 ± 4.0 增加到 26.4 ± 4.1 mmol/L（p <.001），平均 pH 值从 7.40 ± 0.06 增加到 7.42 ± 0.06（p <.001）。总体液体成本从 15077 美元（美国）降至 3915 美元。
在澳大利亚的一个三级重症监护病房，限制富含氯的液体的使用显著影响了电解质和酸碱平衡状态。液体的选择显著调节了危重症患者的酸碱状态。
