Xue Ming, Zhang Xiwen, Liu Feng, Chang Wei, Xie Jianfeng, Xu Jingyuan, Yang Yi, Qiu Haibo
Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, China.
Ann Intensive Care. 2019 Feb 13;9(1):30. doi: 10.1186/s13613-019-0506-y.
Intravenous crystalloid solutions are administered commonly for critically ill patients. We performed this meta-analysis of randomized trials with trial sequential analysis (TSA) to evaluate effects of chloride content of intravenous crystalloid solutions on clinical outcomes among critically ill adult patients.
Electronic databases were searched up to June 1, 2018, for randomized trials of use of balanced crystalloids versus 0.9% saline solutions in critically ill adult patients. The outcome variables included mortality, renal outcomes, serum content alterations and organ function. Subgroup analysis was conducted according to patient settings, types or volume of crystalloid fluid, or among sepsis versus non-sepsis, TBI versus non-TBI or subpopulations by the categories of baseline kidney function. Random errors were evaluated by trial sequential analysis.
Eight studies with 19,301 patients were analyzed. A trend of in-hospital survival benefit with no statistical difference could be observed with balanced crystalloids compared with 0.9% saline (RR 0.92, 95% CI 0.85-1.0, p = 0.06). The use of balanced crystalloid solutions was associated with longer RRT-free days (SMD 0.09, 95% CI 0.06-0.12, p < 0.001), less risk of increase in serum concentrations of chloride (SMD - 1.23, 95% CI - 1.59 to - 0.87, p < 0.001) and sodium (SMD - 1.28, 95% CI - 1.65 to - 0.92, p < 0.001), less risk of decline in serum base deficit (SMD - 0.58, 95% CI - 0.98 to - 0.18, p = 0.004), longer ventilator-free days (SMD 0.08, 95% CI 0.05-0.11, p < 0.001) and vasopressor-free days (SMD 0.04, 95% CI 0.00-0.07, p = 0.02). Subgroup analysis showed that balanced crystalloid solutions were associated with a reduced in-hospital mortality rate among septic patients (RR 0.86, 95% CI 0.75-0.98; p = 0.02) and non-traumatic brain injury patients (RR 0.90, 95% CI 0.82-0.99, p = 0.02), while the TSA results indicated a larger sample size is still in need.
Limited evidence supported statistical survival benefit with balanced crystalloid solutions, while it benefited in reducing organ support duration and fluctuations in serum electrolyte and base excess and was associated with decreased in-hospital mortality in subpopulation with sepsis and non-TBI. Large-scale rigorous randomized trials with better designs are needed to provide robust evidence for clinical management. Trial registration The protocol for this meta-analysis was registered on PROSPERO: International prospective register of systematic reviews (CRD42018102661), https://www.crd.york.ac.uk/prospero/#recordDetails.
静脉输注晶体溶液常用于重症患者。我们进行了这项随机试验的荟萃分析，并采用试验序贯分析（TSA）来评估静脉晶体溶液中氯含量对成年重症患者临床结局的影响。
检索电子数据库至2018年6月1日，查找关于成年重症患者使用平衡晶体液与0.9%生理盐水溶液的随机试验。结局变量包括死亡率、肾脏结局、血清成分改变和器官功能。根据患者情况、晶体液类型或体积，以及脓毒症与非脓毒症、创伤性脑损伤（TBI）与非TBI或按基线肾功能类别划分的亚组进行亚组分析。通过试验序贯分析评估随机误差。
分析了8项研究，共19301例患者。与0.9%生理盐水相比，平衡晶体液可观察到院内生存获益趋势，但无统计学差异（风险比[RR]0.92，95%置信区间[CI]0.85 - 1.0，p = 0.06）。使用平衡晶体溶液与更长的无肾脏替代治疗（RRT）天数相关（标准化均数差[SMD]0.09，95% CI 0.06 - 0.12，p < 0.001），血清氯浓度升高风险降低（SMD -1.23，95% CI -1.59至 -0.87，p < 0.001）以及血清钠浓度升高风险降低（SMD -1.28，95% CI -1.65至 -0.92，p < 0.001），血清碱缺失下降风险降低（SMD -0.58，95% CI -0.98至 -0.18，p = 0.004），更长的无呼吸机天数（SMD 0.08，95% CI 0.05 - 0.11，p < 0.001）和无血管活性药物天数（SMD 0.04，95% CI 0.00 - 0.07，p = 0.02）。亚组分析显示，平衡晶体溶液与脓毒症患者（RR 0.86，95% CI 0.75 - 0.98；p = 0.02）和非创伤性脑损伤患者（RR 0.90，95% CI 0.82 - 0.99，p = 0.02）的院内死亡率降低相关，而TSA结果表明仍需要更大的样本量。
有限的证据支持平衡晶体溶液有统计学意义的生存获益，同时它有助于缩短器官支持时间，减少血清电解质和碱剩余的波动，并且与脓毒症和非TBI亚组患者的院内死亡率降低相关。需要大规模设计更好的严格随机试验为临床管理提供有力证据。试验注册 本荟萃分析方案已在国际前瞻性系统评价注册库（PROSPERO）注册：https://www.crd.york.ac.uk/prospero/#recordDetails（CRD42018102661） 。
