From the Department of Surgery (C.E.B., S.A., B.R.H.R., G.E.O.) and Harborview Injury Prevention and Research Center (S.A., B.R.H.R., G.E.O.), Harborview Medical Center, University of Washington, Seattle, Washington.
J Trauma Acute Care Surg. 2021 Dec 1;91(6):1010-1017. doi: 10.1097/TA.0000000000003373.
Unlike recent advances in blood product resuscitation, intravenous crystalloid (IVF) use after intensive care unit (ICU) admission in hemorrhagic shock has received less attention and current recommendations are based on limited evidence. To address this knowledge gap, we aimed to determine associations between IVF administration during acute ICU resuscitation and outcomes. We hypothesized that larger IVF volumes are associated with worse outcomes.
We linked our trauma registry with electronic health record data (2012-2015) to identify adults with an initial lactate level of ≥4 mmol/L and documented lactate normalization (≤2 mmol/L), excluding those with isolated head Abbreviated Injury Scale score ≥3. We focused on the period from ICU admission to lactate normalization, analyzing duration, volume of IVF, and proportion of volume as 1-L boluses. We used linear regression to determine associations with ICU length of stay and duration of mechanical ventilation in survivors, and logistic regression to identify associations with acute kidney injury and home discharge while adjusting for important covariates.
We included 337 subjects. Median time to lactate normalization was 15 hours (interquartile range, 7-25 hours), and median IVF volume was 3.7 L (interquartile range, 1.5-6.4 L). The fourfold difference between the upper and lower quartiles of both duration and volume remained after stratifying by injury severity. Hourly volumes tapered over time but persistently aggregated at 0.5 and 1 L, with 167 subjects receiving at least one 0.5-L bolus for 6 hours after ICU admission. Administration of larger volumes was associated with longer ICU length of stay and duration of mechanical ventilation, as well as acute kidney injury.
There is substantial variation in volume administered during acute ICU resuscitation, both absolutely and temporally, despite accounting for injury severity. Administration of larger volumes during acute ICU resuscitation is associated with worse outcomes. There is an opportunity to improve outcomes by further investigating and standardizing this important phase of care.
Therapeutic/care management, level IV.
与最近在血液制品复苏方面的进展不同，重症监护病房（ICU）入院后静脉晶体液（IVF）的使用受到的关注较少，目前的建议基于有限的证据。为了解决这一知识空白，我们旨在确定 ICU 复苏期间 IVF 给药与结局之间的关系。我们假设更大的 IVF 体积与更差的结局相关。
我们将创伤登记处与电子健康记录数据（2012-2015 年）相关联，以确定初始乳酸水平≥4mmol/L 且有记录的乳酸正常化（≤2mmol/L）的成年人，排除那些孤立的头部损伤严重程度量表评分≥3 的患者。我们专注于从 ICU 入院到乳酸正常化的时间段，分析持续时间、IVF 量和 1L 推注的体积比例。我们使用线性回归来确定幸存者 ICU 住院时间和机械通气时间的关联，使用逻辑回归来确定急性肾损伤和家庭出院的关联，同时调整重要的协变量。
我们纳入了 337 名患者。中位数达到乳酸正常化的时间为 15 小时（四分位距，7-25 小时），中位数 IVF 量为 3.7L（四分位距，1.5-6.4L）。在按损伤严重程度分层后，持续时间和体积的上下四分位差仍有四倍差异。随着时间的推移，每小时的体积逐渐减少，但仍在 0.5 和 1L 处聚集，有 167 名患者在 ICU 入院后至少接受了 6 小时的 0.5L 推注。给予更大的体积与 ICU 住院时间和机械通气时间延长以及急性肾损伤有关。
尽管考虑到损伤严重程度，但 ICU 复苏期间给予的体积在绝对值和时间上都有很大差异。在 ICU 复苏期间给予更大的体积与更差的结局相关。通过进一步调查和规范这一重要的治疗阶段，有机会改善结局。
治疗/护理管理，IV 级。
