Hemauer Sarah J, Kingeter Adam J, Han Xue, Shotwell Matthew S, Pandharipande Pratik P, Weavind Liza M
1Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, TN. 2Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN.
Crit Care Med. 2017 May;45(5):e479-e484. doi: 10.1097/CCM.0000000000002288.
To determine the association between hemoglobin levels and the daily risk of individual organ dysfunctions in critically ill patients.
Post hoc analysis of prospectively collected data.
Vanderbilt University Medical Center and Saint Thomas Hospital Medical and Surgical ICUs.
Medical and surgical ICU patients admitted with respiratory failure or shock.
Baseline demographic data, and detailed in-ICU and hospital data, including daily lowest hemoglobin, were collected up to hospital day 30. We assessed patients daily for brain dysfunction (delirium, using Confusion Assessment Method for ICU), for renal and respiratory dysfunction (using the ordinal renal and respiratory Sequential Organ Failure Assessment score), and for ICU mortality. Associations between the lowest hemoglobin on a given day and organ dysfunctions the following day were assessed using multivariable regressions, adjusting for age, Acute Physiology and Chronic Health Evaluation II score, Charlson comorbidity index, Framingham Stroke Risk Profile, ICU day, ICU type, sepsis, and current organ dysfunction status. A sensitivity analysis further adjusted for daily transfusions and fluid balance in a subset of our patients.
We enrolled 821 patients with a median (interquartile range) age of 61 (51-71) years, Acute Physiology and Chronic Health Evaluation II score of 25 (19-31), and hemoglobin level of 10.0 (9.0-11.1) g/dL. There was no evidence of an association between lowest daily hemoglobin and brain dysfunction (p = 0.69 for delirium), renal dysfunction (p = 0.30), or ICU mortality (p = 0.95). The lowest hemoglobin on a given day was significantly associated with the respiratory Sequential Organ Failure Assessment score the following day; for each increasing hemoglobin unit, the odds of worsened respiratory Sequential Organ Failure Assessment score the following day were decreased by 36% (OR, 0.64; 95% CI, 0.53-0.77; p < 0.001). The sensitivity analysis including daily transfusions and fluid balance (in a subset of 518 patients) did not qualitatively change any of these associations.
In this study in ICU patients, lower hemoglobin was associated with a higher probability of worsening respiratory dysfunction scores the following day. There was no evidence of association between hemoglobin and brain or renal dysfunction, or ICU mortality. The possible differential effects of anemia on organ dysfunctions seen in this hypothesis-generating study will have to be studied in a larger prospective study before any alterations to present restrictive transfusion guidelines can be recommended.
确定危重症患者血红蛋白水平与各器官功能每日衰竭风险之间的关联。
对前瞻性收集的数据进行事后分析。
范德比尔特大学医学中心和圣托马斯医院内科及外科重症监护病房。
因呼吸衰竭或休克入住内科及外科重症监护病房的患者。
收集基线人口统计学数据以及详细的重症监护病房内和住院期间数据，包括直至住院第30天的每日最低血红蛋白水平。我们每日评估患者的脑功能障碍（使用重症监护病房意识模糊评估法评估谵妄）、肾和呼吸功能障碍（使用序贯器官衰竭评估的肾和呼吸评分）以及重症监护病房死亡率。使用多变量回归评估给定日期的最低血红蛋白水平与次日器官功能障碍之间的关联，并对年龄、急性生理与慢性健康状况评估II评分、查尔森合并症指数、弗雷明汉卒中风险概况、重症监护病房住院天数、重症监护病房类型、脓毒症以及当前器官功能障碍状态进行校正。敏感性分析在部分患者中进一步对每日输血情况和液体平衡进行了校正。
我们纳入了821例患者，年龄中位数（四分位间距）为61（51 - 71）岁，急性生理与慢性健康状况评估II评分为25（19 - 31），血红蛋白水平为10.0（9.0 - 11.1）g/dL。没有证据表明每日最低血红蛋白水平与脑功能障碍（谵妄的p = 0.69）、肾功能障碍（p = 0.30）或重症监护病房死亡率（p = 0.95）之间存在关联。给定日期的最低血红蛋白水平与次日的呼吸序贯器官衰竭评估评分显著相关；血红蛋白每增加一个单位，次日呼吸序贯器官衰竭评估评分恶化的几率降低36%（比值比，0.64；95%置信区间，0.53 - 0.77；p < 0.001）。包括每日输血情况和液体平衡的敏感性分析（在518例患者的子集中）并未使这些关联中的任何一项发生定性改变。
在这项针对重症监护病房患者的研究中，较低的血红蛋白水平与次日呼吸功能障碍评分恶化的较高概率相关。没有证据表明血红蛋白与脑或肾功能障碍以及重症监护病房死亡率之间存在关联。在建议对目前严格的输血指南进行任何更改之前，必须在一项更大规模的前瞻性研究中对本假设生成性研究中所观察到的贫血对器官功能障碍可能存在的不同影响进行研究。
