创伤患者的晶体复苏：24小时内输注5升或更多晶体液的有害影响
Crystalloid resuscitation in trauma patients: deleterious effect of 5L or more in the first 24h.
作者信息
Jones D G, Nantais J, Rezende-Neto J B, Yazdani S, Vegas P, Rizoli S
机构信息
Department of Surgery, University of Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.
St. Michael's Hospital Department of Surgery, University of Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.
出版信息
BMC Surg. 2018 Nov 6;18(1):93. doi: 10.1186/s12893-018-0427-y.
BACKGROUND
Over-aggressive intravenous fluid therapy with crystalloids has adverse effects in trauma patients. We assessed the role of large-volume (≥5l) administration of crystalloids within 24h of injury as an independent risk-factor for mortality, in-hospital complications, and prolonged mechanical ventilation.
METHODS
A retrospective cohort analysis of adult trauma patients admitted to a level 1-trauma center between December 2011 and December 2012. Patient demographics, clinical and laboratory values, and total resuscitation fluid administered within the first 24h of injury were obtained. Outcomes included mortality, in-hospital complications and ventilator-days. Multivariable logistic regression and Poisson regression analyses were performed to investigate any association between the administration of ≥5L crystalloids with the aforementioned outcomes while controlling for selected clinical variables.
RESULTS
A total of 970 patients were included in the analysis. 264 (27%) received ≥5L of crystalloids in the first 24h of injury. 118 (12%) had in-hospital complications and 337 (35%) required mechanical ventilation. The median age was 46 years (interquartile range (IQR) 27-65) years and 73% (n = 708) were males. The median injury severity score (ISS) was 17 (IQR 9-25). Overall mortality rate was 7% (n = 67). Multivariable logistic regression analysis showed several variables independently associated with mortality (p < 0.05), including resuscitation with ≥5L crystalloid in the first 24h (adjusted odds ratio (aOR) 2.55), older age (aOR 1.03), higher ISS (aOR 1.09), and lower temperature (aOR 0.68). The variables independently associated with in-hospital complications (p < 0.05) were older age, longer ICU stay, and platelet transfusion within 24h of the injury. Need for mechanical ventilation was more common in patients who received ≥5L crystalloids (RR 2.31) had higher ISS (RR 1.02), developed in-hospital complications (RR 1.91) and had lower presenting temperature (RR 0.87).
CONCLUSION
Large-volume crystalloid resuscitation is associated with increased mortality and longer time ventilated, but not with in-hospital complications such as pneumonia and sepsis. Based on this data, we recommend judicious use of crystalloids in the resuscitation of trauma patients.
背景
使用晶体液进行过度积极的静脉输液治疗对创伤患者有不良影响。我们评估了在受伤后24小时内大量（≥5升）输注晶体液作为死亡率、院内并发症和机械通气时间延长的独立危险因素的作用。
方法
对2011年12月至2012年12月期间入住一级创伤中心的成年创伤患者进行回顾性队列分析。获取患者的人口统计学资料、临床和实验室值，以及受伤后最初24小时内输注的复苏液体总量。结局指标包括死亡率、院内并发症和呼吸机使用天数。进行多变量逻辑回归和泊松回归分析，以研究在控制选定临床变量的情况下，输注≥5升晶体液与上述结局之间的任何关联。
结果
共有970例患者纳入分析。264例（27%）在受伤后最初24小时内接受了≥5升晶体液。118例（12%）发生院内并发症，337例（35%）需要机械通气。中位年龄为46岁（四分位间距（IQR）27 - 65岁），73%（n = 708）为男性。中位损伤严重度评分（ISS）为17（IQR 9 - 25）。总体死亡率为7%（n = 67）。多变量逻辑回归分析显示，有几个变量与死亡率独立相关（p < 0.05），包括受伤后最初24小时内输注≥5升晶体液进行复苏（调整比值比（aOR）2.55）、年龄较大（aOR 1.03）、ISS较高（aOR 1.09）和体温较低（aOR 0.68）。与院内并发症独立相关（p < 0.05）的变量为年龄较大、ICU住院时间较长以及受伤后24小时内输注血小板。接受≥5升晶体液的患者更常需要机械通气（相对危险度（RR）2.31），ISS较高（RR 1.02），发生院内并发症（RR 1.91），且入院时体温较低（RR 0.87）。
结论
大量晶体液复苏与死亡率增加和机械通气时间延长相关，但与肺炎和脓毒症等院内并发症无关。基于这些数据，我们建议在创伤患者复苏中谨慎使用晶体液。
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