剖腹术后和临时腹部关闭后的高渗盐水复苏。
Hypertonic saline resuscitation after emergent laparotomy and temporary abdominal closure.
机构信息
From the Department of Surgery and Sepsis and Critical Illness Research Center (T.J.L., P.A.E., T.M.B., M.D.R., C.A.C., R.S.S., F.A.M., A.M.M., S.C.B.), University of Florida Health, Gainesville, Florida.
出版信息
J Trauma Acute Care Surg. 2018 Feb;84(2):350-357. doi: 10.1097/TA.0000000000001730.
BACKGROUND
Our objective was to establish the safety of 3% hypertonic saline (HTS) resuscitation for trauma and acute care surgery patients undergoing emergent laparotomy and temporary abdominal closure (TAC) with the hypothesis that HTS administration would be associated with hyperosmolar hypercholoremic acidosis, lower resuscitation volumes, and higher fascial closure rates, without adversely affecting renal function.
METHODS
We performed a retrospective cohort analysis of 189 trauma and acute care surgery patients who underwent emergent laparotomy and TAC, comparing patients with normal baseline renal function who received 3% HTS at 30 mL/h (n = 36) to patients with standard resuscitation (n = 153) by baseline characteristics, resuscitation parameters, and outcomes including primary fascial closure and Kidney Disease: Improving Global Outcomes stages of acute kidney injury.
RESULTS
The HTS and standard resuscitation groups had similar baseline illness severity and organ dysfunction, though HTS patients had lower serum creatinine at initial laparotomy (1.2 mg/dL vs. 1.4 mg/dL; p = 0.078). Forty-eight hours after TAC, HTS patients had significantly higher serum sodium (145.8 mEq/L vs. 142.2 mEq/L, p < 0.001), chloride (111.8 mEq/L vs. 106.6 mEq/L, p < 0.001), and osmolarity (305.8 mOsm/kg vs. 299.4 mOsm/kg; p = 0.006), and significantly lower arterial pH (7.34 vs. 7.38; p = 0.011). The HTS patients had lower intravenous fluid (IVF) volumes within 48 hours of TAC (8.5 L vs. 11.8 L; p = 0.004). Serum creatinine, urine output, and kidney injury were similar between groups. Fascial closure was achieved for 92% of all HTS patients and 77% of all standard resuscitation patients (p = 0.063). Considering all 189 patients, higher IVF resuscitation volumes within 48 hours of TAC were associated with decreased odds of fascial closure (odds ratio, 0.90; 95% confidence interval, 0.83-0.97; p = 0.003).
CONCLUSION
Hypertonic saline resuscitation was associated with the development of a hypernatremic, hyperchloremic, hyperosmolar acidosis, and lower total IVF resuscitation volumes, without adversely affecting renal function. These findings may not be generalizable to patients with baseline renal dysfunction and susceptibility to hyperchloremic acidosis-induced kidney injury.
LEVEL OF EVIDENCE
Prognostic study, level II.
背景
我们的目的是确定在接受紧急剖腹术和临时腹部关闭（TAC）的创伤和急性外科手术患者中使用 3%高渗盐水（HTS）复苏的安全性，假设 HTS 给药将与高渗性高氯性酸中毒、更低的复苏量和更高的筋膜闭合率相关，而不会对肾功能产生不利影响。
方法
我们对 189 例接受紧急剖腹术和 TAC 的创伤和急性外科手术患者进行了回顾性队列分析，将接受 30mL/h 3%HTS 的正常基线肾功能患者（n=36）与接受标准复苏的患者（n=153）进行比较，比较基线特征、复苏参数以及包括原发性筋膜闭合和急性肾损伤肾脏病：改善全球结果（KDIGO）分期在内的结局。
结果
HTS 和标准复苏组的基线疾病严重程度和器官功能障碍相似，但 HTS 患者初始剖腹术时的血清肌酐较低（1.2mg/dL 与 1.4mg/dL；p=0.078）。在 TAC 后 48 小时，HTS 患者的血清钠（145.8mEq/L 与 142.2mEq/L，p<0.001）、氯（111.8mEq/L 与 106.6mEq/L，p<0.001）和渗透压（305.8mOsm/kg 与 299.4mOsm/kg，p=0.006）明显更高，动脉 pH（7.34 与 7.38，p=0.011）明显更低。HTS 患者在 TAC 后 48 小时内的静脉输液（IVF）量较低（8.5L 与 11.8L，p=0.004）。两组间血清肌酐、尿量和肾损伤无差异。所有 HTS 患者中有 92%和所有标准复苏患者中有 77%实现了筋膜闭合（p=0.063）。考虑到所有 189 例患者，TAC 后 48 小时内 IVF 复苏量较高与筋膜闭合几率降低相关（比值比，0.90；95%置信区间，0.83-0.97；p=0.003）。
结论
高渗盐水复苏与高钠血症、高氯血症、高渗性酸中毒以及总 IVF 复苏量减少相关，而不会对肾功能产生不利影响。这些发现可能不适用于基线肾功能障碍和易发生高氯性酸中毒诱导的肾损伤的患者。
证据水平
预后研究，Ⅱ级。
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