da Silva Sirlei Cristina, Consolim-Colombo Fernanda Marciano, Rodrigues Renata Gomes, Gaiotto Fábio Antonio, Hajjar Ludhmila Abrahão, Moysés Rosa Maria Affonso, Elias Rosilene Motta
Instituto do Coração, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil.
Nephrology, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil.
BMC Anesthesiol. 2020 Mar 7;20(1):60. doi: 10.1186/s12871-020-00971-6.
Fluid overload is a risk factor for morbidity, mortality, and prolonged ventilation time after surgery. Patients on maintenance hemodialysis might be at higher risk. We hypothesized that fluid accumulation would be directly associated with extended ventilation time in patients on hemodialysis, as compared to patients with chronic kidney disease not on dialysis (CKD3-4) and patients with normal renal function (reference group).
This is a prospective observational study that included patients submitted to isolated and elective coronary artery bypass surgery, divided in 3 groups according to time on mechanical ventilation: < 24 h, 24-48 h and > 48 h. The same observer followed patients daily from the surgery to the hospital discharge. Cumulative fluid balance was defined as the sum of daily fluid balance over the first 5 days following surgery.
Patients requiring more than 48 h of ventilation (5.3%) had a lower estimated glomerular filtration rate, were more likely to be on maintenance dialysis, had longer anesthesia time, needed higher dobutamine and noradrenaline infusion following surgery, and had longer hospitalization stay. Multivariate analysis revealed that the fluid accumulation, scores of sequential organ failure assessment in the day following surgery, and the renal function (normal, chronic kidney disease not on dialysis and maintenance hemodialysis) were independently associated with time in mechanical ventilation. Among patients on hemodialysis, the time from the surgery to the first hemodialysis session also accounted for the time on mechanical ventilation.
Fluid accumulation is an important risk factor for lengthening mechanical ventilation, particularly in patients on hemodialysis. Future studies are warranted to address the ideal timing for initiating dialysis in this scenario in an attempt to reduce fluid accumulation and avoid prolonged ventilation time and hospital stay.
液体超负荷是术后发病、死亡及通气时间延长的一个危险因素。维持性血液透析患者可能风险更高。我们假设，与未进行透析的慢性肾脏病患者（CKD3-4）及肾功能正常的患者（参照组）相比，血液透析患者的液体蓄积与通气时间延长直接相关。
这是一项前瞻性观察性研究，纳入接受单纯择期冠状动脉搭桥手术的患者，根据机械通气时间分为3组：<24小时、24 - 48小时和>48小时。同一名观察者从手术至出院每日对患者进行随访。累积液体平衡定义为术后前5天每日液体平衡之和。
通气时间超过48小时的患者（5.3%）估算肾小球滤过率较低，更有可能接受维持性透析，麻醉时间更长，术后需要更高剂量的多巴酚丁胺和去甲肾上腺素输注，住院时间也更长。多因素分析显示，液体蓄积、术后第一天序贯器官衰竭评估得分及肾功能（正常、未进行透析的慢性肾脏病和维持性血液透析）与机械通气时间独立相关。在血液透析患者中，从手术至首次血液透析治疗的时间也影响机械通气时间。
液体蓄积是延长机械通气时间的一个重要危险因素，尤其是在血液透析患者中。未来有必要开展研究，以确定在这种情况下开始透析的理想时机，试图减少液体蓄积，避免通气时间延长和住院时间延长。
