Hong Andrew, Villano Nicholas, Toppen William, Elizabeth Aquije Montoya, Berlin David, Cannesson Maxime, Barjaktarevic Igor
David Geffen School of Medicine at University of California Department of Medicine Los Angeles, CA USA.
Weill Cornell Medical College Division of Pulmonary and Critical Care New York, NY USA.
J Acute Med. 2021 Dec 1;11(4):129-140. doi: 10.6705/j.jacme.202112_11(4).0002.
In order to quantify fluid administration and evaluate the clinical consequences of conservative fluid management without hemodynamic monitoring in undifferentiated shock, we analyzed previously collected data from a study of carotid Doppler monitoring as a predictor of fluid responsiveness (FR).
This study was a retrospective analysis of data collected from a single tertiary academic center from a previous study. Seventy-four patients were included for post-hoc analysis, and 52 of them were identified as fluid responsive (cardiac output increase > 10% with passive leg raise) according to NICOMTM bioreactance monitoring (Cheetah Medical, Newton Center, MA, USA). Treating teams provided standard of care conservative fluid resuscitation but were blinded to independently performed FR testing results. Outcomes were compared between fluid responsive and fluid non-responsive patients. Primary outcome measures were volume fluids administered and net fluid balance 24- and 72-hour post-FR assessment. Secondary outcome measures included change in vasopressor requirements, mean peak lactate levels, length of hospital/intensive care unit stay, acute respiratory failure, hemodialysis requirement, and durations of vasopressors and mechanical ventilation.
Mean fluids administered within 72 hours were similar between fluid non-responsive and fluid responsive patients (139 mL/kg [95% confidence interval [CI]: 102.00-175.00] vs. 136 mL/kg [95% CI: 113.00-158.00], p = 0.92, respectively). We observed an insignificant trend toward higher 28-day mortality among fluid non-responsive patients (36% vs. 19%, p = 0.14). Volume of fluids administered significantly correlated with adverse outcomes such as increased hemodialysis requirements (32 patients, 43%), (odds ratio [OR] = 1.7200, p = 0.0018). Subgroup analysis suggested administering ≥ 30 mL/kg fluids to fluid responsive patients had a trend toward increased mortality (25% vs. 0%, p = 0.09) and a significant increase in hemodialysis (55% vs. 17%, p = 0.024).
Without formal FR assessment, similar amounts of total fluids were administered in both fluid responsive and non-responsive patients. As greater volumes of intravenous fluids administered were associated with adverse outcomes, we suggest that dedicated FR assessment may be a beneficial utility in early shock resuscitation.
为了量化液体输注量，并评估在未分化休克中不进行血流动力学监测的保守液体管理的临床后果，我们分析了先前一项关于颈动脉多普勒监测作为液体反应性（FR）预测指标的研究中收集的数据。
本研究是对先前一项研究中从单个三级学术中心收集的数据进行的回顾性分析。74例患者纳入事后分析，其中52例根据NICOMTM生物反应监测（美国马萨诸塞州牛顿中心的猎豹医疗公司）被确定为液体反应性患者（被动抬腿时心输出量增加>10%）。治疗团队提供标准的保守液体复苏治疗，但对独立进行的FR检测结果不知情。比较液体反应性和非反应性患者的结局。主要结局指标为FR评估后24小时和72小时的液体输注量和净液体平衡。次要结局指标包括血管升压药需求量的变化、平均乳酸峰值水平、住院/重症监护病房住院时间、急性呼吸衰竭、血液透析需求以及血管升压药和机械通气的持续时间。
液体非反应性和反应性患者72小时内的平均液体输注量相似（分别为139 mL/kg [95%置信区间[CI]：102.00 - 175.00]和136 mL/kg [95% CI：113.00 - 158.00]，p = 0.92）。我们观察到液体非反应性患者28天死亡率有升高趋势，但无统计学意义（36%对19%，p = 0.14）。液体输注量与不良结局显著相关，如血液透析需求增加（32例患者，43%），（比值比[OR] = 1.7200，p = 0.0018）。亚组分析表明，给液体反应性患者输注≥30 mL/kg液体有死亡率升高趋势（25%对0%，p = 0.09），且血液透析显著增加（55%对17%，p = 0.024）。
在未进行正式FR评估的情况下，液体反应性和非反应性患者的总液体输注量相似。由于静脉输液量增加与不良结局相关，我们建议在早期休克复苏中进行专门的FR评估可能有益。
