Wang Hao, Cui Na, Su Longxiang, Long Yun, Wang Xiaoting, Zhou Xiang, Chai Wenzhao, Liu Dawei
Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing 100730, China.
Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing 100730, China.
J Crit Care. 2016 Jun;33:106-13. doi: 10.1016/j.jcrc.2016.02.011. Epub 2016 Feb 24.
To explore whether extravascular lung water (EVLW) provides a valuable prognostic tool guiding fluid therapy in septic shock patients after initial resuscitation.
We performed a retrospective study of septic shock patients who achieved adequate initial fluid resuscitation with extended hemodynamic monitoring, analyzing the prognostic value of EVLW and whether fluid therapy for 24 (T24) or 24-48 hours (T24-48) after initial resuscitation with a recommended value of EVLW yielded a 28-day mortality advantage.
One hundred five patients with septic shock were included in this study, 60 (57.1%) of whom died after 28 days. For 48 hours after initial resuscitation, the daily fluid balance (DFB; T24: 2494 ± 1091 vs 1965 ± 964 mL [P = .011] and T24-48: 2127 ± 783 vs 1588 ± 665 mL [P < .001]) and daily maximum values of the EVLW index (EVLWImax; T24: 13.9 ± 3.7 vs 11.5 ± 3.2 mL/kg [P < .001] and T24-48: 14.4 ± 5.3 vs 12.0 ± 4.4 mL/kg [P < .001]) were significantly higher in nonsurvivors than in survivors. In multivariate regression analysis, the DFB (T24: odds ratio [OR] 1.001 [P = .016] and T24-48: OR 1.001 [P = .008]), EVLWImax (T24: OR 2.158 [P = .002] and T24-48: OR 3.277 [P = .001]), blood lactate (T24: OR 1.368 [P = .021] and T24-48: OR 4.112 [P < .001]), and central venous blood oxygen saturation (T24: OR 0.893 [P = .013] and T24-48: OR 0.780 [P = .004]) were all independently associated with the 28-day mortality. A receiver operating characteristic analysis revealed that area under the curve values of 0.82 (95% confidence interval, 0.74-0.91; P < .001) and 0.90 (95% confidence interval, 0.83-0.96; P < .001) for EVLWImax ≥ 12.5 mL/kg (T24 and T24-48) predicted a 28-day mortality with sensitivities of 88% (80%-96%) and 95% (90%-100%) and specificities of 60% (46%-74%) and 76% (63%-89%).The EVLWImax was correlated with DFB with Spearman ρ values of 0.497 (T24: P < .001) and 0.650 (T24-48: P < .001). Cox survival and regression analyses demonstrated that EVLWImax ≥ 12.5 mL/kg (T24 and T24-48) was associated with higher risk and increased mortality, with adjusted ORs of 4.77 (P < .001) and 10.86 (P < .001).
A higher EVLW in septic shock patients after initial resuscitation was associated with a more positive fluid balance and increased mortality, which is an independent predictor of the 28-day mortality in septic shock patients after initial resuscitation.
探讨血管外肺水（EVLW）是否可作为一种有价值的预后工具，用于指导感染性休克患者初始复苏后的液体治疗。
我们对经充分初始液体复苏并进行了长时间血流动力学监测的感染性休克患者进行了一项回顾性研究，分析EVLW的预后价值，以及初始复苏后根据EVLW推荐值进行24小时（T24）或24 - 48小时（T24 - 48）液体治疗是否能带来28天死亡率方面的优势。
本研究纳入了105例感染性休克患者，其中60例（57.1%）在28天后死亡。初始复苏后48小时内，非存活者的每日液体平衡（DFB；T24：2494±1091 vs 1965±964 mL [P = 0.011]，T24 - 48：2127±783 vs 1588±665 mL [P < 0.001]）和EVLW指数的每日最大值（EVLWImax；T24：13.9±3.7 vs 11.5±3.2 mL/kg [P < 0.001]，T24 - 48：14.4±5.3 vs 12.0±4.4 mL/kg [P < 0.001]）均显著高于存活者。在多因素回归分析中，DFB（T24：比值比[OR] 1.001 [P = 0.016]，T24 - 48：OR 1.001 [P = 0.008]）、EVLWImax（T24：OR 2.158 [P = 0.002]，T24 - 48：OR 3.277 [P = 0.001]）、血乳酸（T24：OR 1.368 [P = 0.021]，T24 - 48：OR 4.112 [P < 0.001]）和中心静脉血氧饱和度（T24：OR 0.893 [P = 0.013]，T24 - 48：OR 0.780 [P = 0.004]）均与28天死亡率独立相关。受试者工作特征分析显示，EVLWImax≥12.5 mL/kg（T24和T24 - 48）的曲线下面积值分别为0.82（95%置信区间，0.74 - 0.91；P < 0.001）和0.90（95%置信区间，0.83 - 0.96；P < 0.001），预测28天死亡率的敏感性分别为88%（80% - 96%）和95%（90% - 100%），特异性分别为60%（46% - 74%）和76%（63% - 89%）。EVLWImax与DFB相关，Spearman ρ值在T24时为0.497（P < 0.001），在T24 - 48时为0.650（P < 0.001）。Cox生存和回归分析表明，EVLWImax≥12.5 mL/kg（T24和T24 - 48）与更高风险和死亡率增加相关，校正后的OR分别为4.77（P < 0.001）和10.86（P < 0.001）。
感染性休克患者初始复苏后较高的EVLW与更正向的液体平衡及死亡率增加相关，这是感染性休克患者初始复苏后28天死亡率的独立预测因素。
