早期纠正钠代谢紊乱对危重症患者生存的影响。

Influence of early dysnatremia correction on survival of critically ill patients.

作者信息

Darmon Michael, Pichon Matthias, Schwebel Carole, Ruckly Stéphane, Adrie Christophe, Haouache Hakim, Azoulay Elie, Bouadma Lila, Clec'h Christophe, Garrouste-Orgeas Maïté, Souweine Bertrand, Goldgran-Toledano Dany, Khallel Hatem, Argaud Laurent, Dumenil Anne-Sylvie, Jamali Samir, Allaouchiche Bernard, Zeni Fabrice, Timsit Jean-François

机构信息

*Medical Intensive Care Unit, Saint-Etienne University Hospital, Avenue Albert Raymond, Saint-Priest en Jarez; †Jacques Lisfranc Medical School, Saint-Etienne University, Saint-Etienne; ‡University of Grenoble 1 (Joseph Fourier) Integrated Research Center, Albert Bonniot Institute, and §Polyvalent Intensive Care Unit, Grenoble University Hospital, Grenoble; ∥Department of Physiology, Cochin University Hospital, Paris; ¶Surgical Intensive Care Unit, Mondor University Hospital, Créteil; **Medical Intensive Care Unit, University Hospital St Louis; and ††Medical Intensive Care Unit, Bichat University Hospital, Paris; ‡‡Medical-Surgical Intensive Care Unit, Avicenne University Hospital, Bobigny; §§Polyvalent Intensive Care Unit, Groupe Hospitalier St Joseph, Paris; ∥∥Medical Intensive Care Unit, Gabriel Montpied University Hospital, Clermont Ferrand; ¶¶Polyvalent Intensive Care Unit, Gonesse General Hospital, Gonesse; ***Intensive Care Unit, Centre Hospitalier Andrée Rosemon, Cayenne; †††Medical Intensive Care Unit, Hospices Civils de Lyon, Edouard Herriot University Hospital; and ‡‡‡Lyon University, Lyon-Est Medical School, Lyon; §§§Surgical Intensive Care Unit, Antoine Béclère University Hospital, Clamart; ∥∥∥Polyvalent Intensive Care Unit, Centre Hospitalier Sud Essonne Dourdan-Etampes-Siège, Etampes; and ****Surgical Intensive Care Unit, Edouard Herriot University Hospital, Hospices Civiles de Lyon, Lyon, France.

出版信息

Shock. 2014 May;41(5):394-9. doi: 10.1097/SHK.0000000000000135.

DOI:10.1097/SHK.0000000000000135

PMID:24667611

Abstract

Increasing evidence suggests that dysnatremia at intensive care unit (ICU) admission may predict mortality. Little information is available, however, on the potential effect of dysnatremia correction. This is an observational multicenter cohort study in patients admitted between 2005 and 2012 to 18 French ICUs. Hyponatremia and hypernatremia were defined as serum sodium concentration less than 135 and more than 145 mmol/L, respectively. We assessed the influence on day 28 mortality of dysnatremia correction by day 3 and of the dysnatremia correction rate. Of 7,067 included patients, 1,830 (25.9%) had hyponatremia and 634 (9.0%) had hypernatremia at ICU admission (day 1). By day 3, hyponatremia had been corrected in 1,019 (1,019/1,830; 55.7%) and hypernatremia in 393 (393/634; 62.0%) patients. After adjustment for confounders, persistent hyponatremia or hypernatremia on day 3 was independently associated with higher day 28 mortality (odds ratio [OR], 1.31; 95% confidence interval [95% CI], 1.06 - 1.61; and OR, 1.86; 95% CI, 1.37 - 2.54; respectively). Hyponatremia corrected by day 3, hypernatremia corrected by day 3, and ICU-acquired hyponatremia were not associated with day 28 mortality. Median correction rate from days 1 to 3 was 2.58 mmol/L per day (interquartile range, 0.67 - 4.55). Higher natremia correction rate was associated with lower crude and adjusted day 28 mortality rates (OR per mmol/L per day, 0.97; 95% CI, 0.94 - 1.00; P = 0.04; and OR per mmol/L per day, 0.93; 95% CI, 0.90 - 0.97; P = 0.0003, respectively). Our results indicate that dysnatremia correction is independently associated with survival, with the effect being greater with faster correction rates of up to 12 mmol/L per day.

摘要

越来越多的证据表明，重症监护病房（ICU）入院时的钠代谢紊乱可能预示着死亡率。然而，关于纠正钠代谢紊乱的潜在影响，目前所知甚少。这是一项对2005年至2012年间入住18家法国ICU的患者进行的观察性多中心队列研究。低钠血症和高钠血症分别定义为血清钠浓度低于135 mmol/L和高于145 mmol/L。我们评估了在第3天纠正钠代谢紊乱以及钠代谢紊乱纠正率对第28天死亡率的影响。在纳入研究的7067例患者中，1830例（25.9%）在ICU入院（第1天）时患有低钠血症，634例（9.0%）患有高钠血症。到第3天，1019例（1019/1830；55.7%）低钠血症患者和393例（393/634；62.0%）高钠血症患者的钠代谢紊乱得到了纠正。在对混杂因素进行调整后，第3天持续存在的低钠血症或高钠血症与第28天较高的死亡率独立相关（优势比[OR]分别为1.31；95%置信区间[95%CI]为1.06 - 1.61；以及OR为1.86；95%CI为1.37 - 2.54）。第3天纠正的低钠血症、第3天纠正的高钠血症以及ICU获得性低钠血症与第28天死亡率无关。第1天至第3天的中位纠正率为每天2.58 mmol/L（四分位间距为0.67 - 4.55）。较高的钠纠正率与较低的第28天粗死亡率和调整后死亡率相关（每天每mmol/L的OR分别为0.97；95%CI为0.94 - 1.00；P = 0.04；以及每天每mmol/L的OR为0.93；95%CI为0.90 - 0.97；P = 0.0003）。我们的结果表明，纠正钠代谢紊乱与生存率独立相关，每天高达12 mmol/L的更快纠正率效果更佳。