Seitz Kevin P, Caldwell Ellen S, Hough Catherine L
Division of Pulmonary, Allergy, and Critical Care Medicine, Vanderbilt University, Nashville, TN USA.
Vanderbilt University Medical Center, T1218 MCN, 1161 21st Avenue, Nashville, TN 37232 USA.
J Intensive Care. 2020 Oct 12;8:78. doi: 10.1186/s40560-020-00496-7. eCollection 2020.
Acute respiratory distress syndrome (ARDS) and volume overload are associated with increased hospital mortality. Evidence supports conservative fluid management in ARDS, but whether current practice reflects the implementation of that evidence has not been described. This study reports the variability in contemporary fluid management for ICU patients with ARDS. We compared routine care to trial protocols and analyzed whether more conservative management with diuretic medications in contemporary, usual care is associated with outcomes.
We performed a retrospective cohort study in nine ICUs at two academic hospitals during 2016 and 2017. We included 234 adult patients with ARDS in an ICU at least 3 days after meeting moderate-severe ARDS criteria (PaO:FIO ≤ 150). The primary exposure was any diuretic use in 48 to 72 h after meeting ARDS criteria. The primary outcome was hospital mortality. Unadjusted statistical analyses and multivariable logistic regression were used.
In 48-72 h after meeting ARDS criteria, 116 patients (50%) received a diuretic. In-hospital mortality was lower in the group that received diuretics than in the group that did not (14% vs 25%; = 0.025). At ARDS onset, both groups had similar Sequential Organ Failure Assessment scores and ICU fluid balances. During the first 48 h after ARDS, the diuretic group received less crystalloid fluid than the no diuretic group (median [inter-quartile range]: 1.2 L [0.2-2.8] vs 2.4 L [1.2-5.0]; < 0.001), but both groups received more fluid from medications and nutrition than from crystalloid. At 48 h, the prevalence of volume overload (ICU fluid balance >10% of body weight) in each group was 16% and 25%( = 0.09), respectively. During 48-72 h after ARDS, the overall prevalence of shock was 44% and similar across both groups. Central venous pressure was recorded in only 18% of patients. Adjusting for confounders, early diuretic use was independently associated with lower hospital mortality (AOR 0.46, 95%CI [0.22, 0.96]).
In this sample of ARDS patients, volume overload was common, and early diuretic use was independently associated with lower hospital mortality. These findings support the importance of fluid management in ARDS and suggest opportunities for further study and implementation of conservative fluid strategies into usual care.
急性呼吸窘迫综合征（ARDS）和容量超负荷与医院死亡率增加相关。有证据支持对ARDS患者进行保守的液体管理，但目前的实践是否反映了该证据的实施情况尚未得到描述。本研究报告了当代ARDS重症监护病房（ICU）患者液体管理的变异性。我们将常规治疗与试验方案进行了比较，并分析了在当代常规治疗中使用利尿剂进行更保守的管理是否与预后相关。
我们在2016年至2017年期间对两家学术医院的9个ICU进行了一项回顾性队列研究。我们纳入了234例成年ARDS患者，这些患者在符合中重度ARDS标准（PaO₂:FIO₂≤150）至少3天后入住ICU。主要暴露因素是在符合ARDS标准后48至72小时内使用任何利尿剂。主要结局是医院死亡率。采用未调整的统计分析和多变量逻辑回归分析。
在符合ARDS标准后的48 - 72小时内，116例患者（50%）使用了利尿剂。使用利尿剂的组院内死亡率低于未使用利尿剂的组（14%对25%；P = 0.025）。在ARDS发病时，两组的序贯器官衰竭评估评分和ICU液体平衡相似。在ARDS后的前48小时内，使用利尿剂的组比未使用利尿剂的组接受的晶体液更少（中位数[四分位间距]：1.2L[0.2 - 2.8]对2.4L[1.2 - 5.0]；P < 0.001），但两组从药物和营养中获得的液体比从晶体液中获得的更多。在48小时时，每组容量超负荷（ICU液体平衡>体重的10%）的患病率分别为16%和25%（P = 0.09）。在ARDS后的48 - 72小时内，休克的总体患病率为44%，两组相似。仅18%的患者记录了中心静脉压。校正混杂因素后，早期使用利尿剂与较低的医院死亡率独立相关（比值比0.46，95%置信区间[0.22，0.96]）。
在这个ARDS患者样本中，容量超负荷很常见，早期使用利尿剂与较低的医院死亡率独立相关。这些发现支持了ARDS患者液体管理的重要性，并提示了进一步研究以及将保守液体策略应用于常规治疗的机会。
