1Department of Pediatrics, University of Virginia Health Sciences System, Charlottesville, VA. 2Department of Pediatrics, Penn State M.S. Hershey Medical Center, Hershey, PA. 3Department of Pediatrics, Children's Hospital and Medical Center of the University of Nebraska, Omaha, NE. 4Department of Internal Medicine, University of Virginia Health Sciences System, Charlottesville, VA. 5Public Health Sciences, University of Virginia Health Sciences System, Charlottesville, VA. 6Department of Pediatrics, Children's Hospital Cleveland Clinic, Cleveland, OH. 7Pneuma Pharmaceuticals, Buffalo, NY. 8Department of Pediatrics, State University of New York at Buffalo, Buffalo, NY.
Pediatr Crit Care Med. 2013 Sep;14(7):666-72. doi: 10.1097/PCC.0b013e3182917cb5.
Adult studies have demonstrated the relationship between fluid overload and poor outcomes in acute lung injury/acute respiratory distress syndrome. The approach of pediatric intensivists to fluid management in acute lung injury/acute respiratory distress syndrome and its effect on outcomes is less clear. In a post hoc analysis of our Calfactant in Acute Respiratory Distress Syndrome trial, we examined the relationship of fluid balance to in-hospital outcomes in subjects with acute lung injury/acute respiratory distress syndrome.
Calfactant in Acute Respiratory Distress Syndrome was a masked randomized controlled trial of calfactant surfactant versus placebo in pediatric patients with acute lung injury/acute respiratory distress syndrome due to direct lung injury. Caregivers were encouraged to follow a conservative fluid management guideline based on the adult Fluid and Catheter Treatment Trial. Daily fluid balance was collected for the first 7 days after trial enrollment and correlated with clinical outcomes.
Children admitted to PICUs with acute lung injury/acute respiratory distress syndrome from 24 children's hospitals in six different countries.
Post hoc analysis of daily fluid balance in subjects from the Pediatric Calfactant in Acute Respiratory Distress Syndrome trial.
Despite the conservative fluid guideline, fluid management was more consistent with a "liberal" approach. On average, study subjects accumulated 1.96 ± 4.2 L/m over the first 7 days of the trial. Subjects who died accumulated on average 8.7 ± 9.5 L/m versus 1.2 ± 2.4 L/m in survivors. Increasing fluid accumulation was associated with fewer ventilator-free days and worsening oxygenation. Multivariable regression models that included age, gender, Pediatric Risk of Mortality score, initial oxygen saturation index and PaO2/FIO2 ratio, injury category, and treatment arm failed to account for the differences in fluid management.
Pediatric intensivists generally follow a "liberal" approach to fluid management in children with acute lung injury/acute respiratory distress syndrome. Illness severity or oxygenation disturbance did not explain differences in fluid accumulation but such accumulation was associated with worsening oxygenation, a longer ventilator course, and increased mortality. A more conservative approach to fluid management may improve outcomes in children with acute lung injury/acute respiratory distress syndrome.
成人研究已经证明了液体超负荷与急性肺损伤/急性呼吸窘迫综合征不良结局之间的关系。儿科重症监护医师在急性肺损伤/急性呼吸窘迫综合征中的液体管理方法及其对结局的影响尚不清楚。在我们的 Calfactant 在急性呼吸窘迫综合征试验的事后分析中，我们检查了液体平衡与急性肺损伤/急性呼吸窘迫综合征受试者住院期间结局的关系。
Calfactant 在急性呼吸窘迫综合征是一项卡前列素表面活性剂与安慰剂在儿科患者中的随机对照试验，这些患者因直接肺损伤而患有急性肺损伤/急性呼吸窘迫综合征。护理人员被鼓励根据成人液体和导管治疗试验遵循保守的液体管理指南。在试验登记后的前 7 天内每天收集液体平衡，并与临床结果相关联。
来自六个不同国家的 24 家儿童医院重症监护病房收治的急性肺损伤/急性呼吸窘迫综合征患儿。
对来自儿科卡前列素素在急性呼吸窘迫综合征试验的受试者的每日液体平衡进行事后分析。
尽管采用了保守的液体指南，但液体管理更符合“宽松”的方法。平均而言，研究对象在试验的前 7 天内累计积累了 1.96 ± 4.2 L/m。死亡的受试者平均积累了 8.7 ± 9.5 L/m，而幸存者为 1.2 ± 2.4 L/m。液体积累的增加与无呼吸机天数减少和氧合恶化有关。包括年龄、性别、儿科死亡率评分、初始氧饱和度指数和 PaO2/FIO2 比、损伤类别和治疗臂在内的多变量回归模型无法解释液体管理差异。
儿科重症监护医师通常在急性肺损伤/急性呼吸窘迫综合征患儿中采用“宽松”的液体管理方法。疾病严重程度或氧合障碍不能解释液体蓄积的差异，但这种蓄积与氧合恶化、呼吸机使用时间延长和死亡率增加有关。更保守的液体管理方法可能会改善急性肺损伤/急性呼吸窘迫综合征患儿的结局。
