基于P/F和呼气末正压对有创通气的低氧血症重症监护病房患者进行预后分类——来自MARS研究的见解

Prognostic classification based on P/F and PEEP in invasively ventilated ICU patients with hypoxemia-insights from the MARS study.

作者信息

Simonis Fabienne D, Schouten Laura R A, Cremer Olaf L, Ong David S Y, Amoruso Gabriele, Cinella Gilda, Schultz Marcus J, Bos Lieuwe D

机构信息

Department of Intensive Care, Amsterdam University Medical Centers, location AMC, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands.

Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands.

出版信息

Intensive Care Med Exp. 2020 Dec 18;8(Suppl 1):43. doi: 10.1186/s40635-020-00334-y.

DOI:10.1186/s40635-020-00334-y

PMID:33336322

原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC7746417/

Abstract

BACKGROUND

Outcome prediction in patients with acute respiratory distress syndrome (ARDS) greatly improves when patients are reclassified based on predefined arterial oxygen partial pressure to fractional inspired oxygen ratios (PaO/FiO) and positive end-expiratory pressure (PEEP) cutoffs 24 h after the initial ARDS diagnosis. The aim of this study was to test whether outcome prediction improves when patients are reclassified based on predefined PaO/FiO and PEEP cutoffs 24 h after development of mild hypoxemia while not having ARDS.

METHODS

Post hoc analysis of a large prospective, multicenter, observational study that ran in the ICUs of two academic hospitals in the Netherlands between January 2011 and December 2013. Patients were classified into four groups using predefined cutoffs for PaO/FiO (250 mmHg) and PEEP (5 cm HO), both at onset of hypoxemia and after 24 h: PaO/FiO ≥ 250 mmHg and PEEP < 6 cm HO (group I), PaO/FiO ≥ 250 mmHg and PEEP ≥ 6 cm HO (group II), PaO/FiO < 250 mmHg and PEEP < 6 cm HO (group III), and PaO/FiO < 250 mmHg and PEEP ≥ 6 cm HO (group IV), to look for trend association with all-cause in-hospital mortality, the primary outcome. Secondary outcome were ICU- and 90-day mortality, and the number of ventilator-free days or ICU-free days and alive at day 28.

RESULTS

The analysis included 689 consecutive patients. All-cause in-hospital mortality was 35%. There was minimal variation in mortality between the four groups at onset of hypoxemia (33, 36, 38, and 34% in groups I to IV, respectively; P = 0.65). Reclassification after 24 h resulted in a strong trend with increasing mortality from group I to group IV (31, 31, 37, and 48% in groups I to IV, respectively; P < 0.01). Similar trends were found for the secondary endpoints.

CONCLUSIONS

Reclassification using PaO/FiO and PEEP cutoffs after 24 h improved classification for outcome in invasively ventilated ICU patients with hypoxemia not explained by ARDS, compared to classification at onset of hypoxemia.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01905033. Registered on July 11, 2013. Retrospectively registered.

摘要

背景

对于急性呼吸窘迫综合征（ARDS）患者，若根据初始ARDS诊断后24小时预定义的动脉血氧分压与吸入氧分数比（PaO₂/FiO₂）及呼气末正压（PEEP）临界值进行重新分类，其预后预测会显著改善。本研究旨在测试对于未发生ARDS但出现轻度低氧血症的患者，在低氧血症发生24小时后根据预定义的PaO₂/FiO₂和PEEP临界值进行重新分类时，预后预测是否会得到改善。

方法

对2011年1月至2013年12月在荷兰两家学术医院重症监护病房进行的一项大型前瞻性、多中心观察性研究进行事后分析。在低氧血症发作时及24小时后，使用预定义的PaO₂/FiO₂（250 mmHg）和PEEP（5 cmH₂O）临界值将患者分为四组：PaO₂/FiO₂≥250 mmHg且PEEP<6 cmH₂O（I组），PaO₂/FiO₂≥250 mmHg且PEEP≥6 cmH₂O（II组），PaO₂/FiO₂<250 mmHg且PEEP<6 cmH₂O（III组），以及PaO₂/FiO₂<250 mmHg且PEEP≥6 cmH₂O（IV组），以寻找与全因院内死亡率（主要结局）的趋势关联。次要结局为重症监护病房（ICU）和90天死亡率，以及无呼吸机天数或无ICU天数和28天时存活情况。

结果

分析纳入689例连续患者。全因院内死亡率为35%。低氧血症发作时四组之间的死亡率差异极小（I至IV组分别为33%、36%、38%和34%；P = 0.65）。24小时后重新分类显示，从I组到IV组死亡率呈显著上升趋势（I至IV组分别为31%、31%、37%和48%；P<0.01）。次要终点也发现了类似趋势。