采用简化保守方案对急性呼吸窘迫综合征进行液体管理*
Fluid management with a simplified conservative protocol for the acute respiratory distress syndrome*.
作者信息
Grissom Colin K, Hirshberg Eliotte L, Dickerson Justin B, Brown Samuel M, Lanspa Michael J, Liu Kathleen D, Schoenfeld David, Tidswell Mark, Hite R Duncan, Rock Peter, Miller Russell R, Morris Alan H
机构信息
1Division of Critical Care Medicine, Intermountain Medical Center, Murray, UT. 2Division of Pulmonary and Critical Care, Department of Medicine, University of Utah, Salt Lake City, UT. 3Division of Pediatric Critical Care, University of Utah, Salt Lake City, UT. 4College of Pharmacy, University of Utah, Salt Lake City, UT. 5Division of Nephrology, University of California San Francisco, San Francisco, CA. 6Division of Critical Care Medicine, University of California San Francisco, San Francisco, CA. 7Biostatistics Center, Massachusetts General Hospital, Boston, MA. 8Division of Pulmonary and Critical Care Medicine, Baystate Medical Center, Springfield, MA. 9Respiratory Institute, Cleveland Clinic, Cleveland, OH. 10Department of Anesthesiology, University of Maryland, Baltimore, MD.
出版信息
Crit Care Med. 2015 Feb;43(2):288-95. doi: 10.1097/CCM.0000000000000715.
OBJECTIVES
In the Fluid and Catheter Treatment Trial (FACTT) of the National Institutes of Health Acute Respiratory Distress Syndrome Network, a conservative fluid protocol (FACTT Conservative) resulted in a lower cumulative fluid balance and better outcomes than a liberal fluid protocol (FACTT Liberal). Subsequent Acute Respiratory Distress Syndrome Network studies used a simplified conservative fluid protocol (FACTT Lite). The objective of this study was to compare the performance of FACTT Lite, FACTT Conservative, and FACTT Liberal protocols.
DESIGN
Retrospective comparison of FACTT Lite, FACTT Conservative, and FACTT Liberal. Primary outcome was cumulative fluid balance over 7 days. Secondary outcomes were 60-day adjusted mortality and ventilator-free days through day 28. Safety outcomes were prevalence of acute kidney injury and new shock.
SETTING
ICUs of Acute Respiratory Distress Syndrome Network participating hospitals.
PATIENTS
Five hundred three subjects managed with FACTT Conservative, 497 subjects managed with FACTT Liberal, and 1,124 subjects managed with FACTT Lite.
INTERVENTIONS
Fluid management by protocol.
MEASUREMENTS AND MAIN RESULTS
Cumulative fluid balance was 1,918 ± 323 mL in FACTT Lite, -136 ± 491 mL in FACTT Conservative, and 6,992 ± 502 mL in FACTT Liberal (p < 0.001). Mortality was not different between groups (24% in FACTT Lite, 25% in FACTT Conservative and Liberal, p = 0.84). Ventilator-free days in FACTT Lite (14.9 ± 0.3) were equivalent to FACTT Conservative (14.6 ± 0.5) (p = 0.61) and greater than in FACTT Liberal (12.1 ± 0.5, p < 0.001 vs Lite). Acute kidney injury prevalence was 58% in FACTT Lite and 57% in FACTT Conservative (p = 0.72). Prevalence of new shock in FACTT Lite (9%) was lower than in FACTT Conservative (13%) (p = 0.007 vs Lite) and similar to FACTT Liberal (11%) (p = 0.18 vs Lite).
CONCLUSIONS
FACTT Lite had a greater cumulative fluid balance than FACTT Conservative but had equivalent clinical and safety outcomes. FACTT Lite is an alternative to FACTT Conservative for fluid management in Acute Respiratory Distress Syndrome.
目的
在美国国立卫生研究院急性呼吸窘迫综合征网络进行的液体与导管治疗试验（FACTT）中，与宽松液体方案（FACTT宽松组）相比，保守液体方案（FACTT保守组）可降低累积液体平衡并改善预后。随后急性呼吸窘迫综合征网络的研究采用了简化的保守液体方案（FACTT简化组）。本研究的目的是比较FACTT简化组、FACTT保守组和FACTT宽松组方案的实施效果。
设计
对FACTT简化组、FACTT保守组和FACTT宽松组进行回顾性比较。主要结局是7天内的累积液体平衡。次要结局是60天校正死亡率和至第28天的无呼吸机天数。安全性结局是急性肾损伤和新发休克的发生率。
地点
急性呼吸窘迫综合征网络参与医院的重症监护病房。
患者
503例采用FACTT保守组方案治疗的患者、497例采用FACTT宽松组方案治疗的患者和1124例采用FACTT简化组方案治疗的患者。
干预措施
按方案进行液体管理。
测量指标与主要结果
FACTT简化组的累积液体平衡为1918±323 mL，FACTT保守组为-136±491 mL，FACTT宽松组为6992±502 mL（p<0.001）。各组间死亡率无差异（FACTT简化组为24%，FACTT保守组和FACTT宽松组均为25%，p=0.84）。FACTT简化组的无呼吸机天数（14.9±0.3）与FACTT保守组（14.6±0.5）相当（p=0.61），且长于FACTT宽松组（12.1±0.5，与简化组相比p<0.001）。FACTT简化组急性肾损伤发生率为58%，FACTT保守组为57%（p=0.72）。FACTT简化组新发休克发生率（9%）低于FACTT保守组（13%）（与简化组相比p=0.007），与FACTT宽松组（11%）相似（与简化组相比p=0.18）。
结论
FACTT简化组的累积液体平衡高于FACTT保守组，但临床和安全性结局相当。FACTT简化组是急性呼吸窘迫综合征液体管理中FACTT保守组的替代方案。
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