Isha Shahin, Satashia Parthkumar H, Yarrarapu Siva Naga S, Govero Austin B, Harrison Michael F, Baig Hassan Z, Guru Pramod, Bhattacharyya Anirban, Ball Colleen T, Caples Sean M, Grek Ami A, Vizzini Michael R, Khan Syed Anjum, Heise Katherine J, Sekiguchi Hiroshi, Cantrell Warren L, Smith Jeffrey D, Chaudhary Sanjay, Gnanapandithan Karthik, Thompson Kristine M, Graham Charles G, Cowdell Jed C, Murawska Baptista Aleksandra, Libertin Claudia R, Moreno Franco Pablo, Sanghavi Devang K
Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States.
Department of Emergency Medicine, Mayo Clinic, Jacksonville, FL, United States.
Front Med (Lausanne). 2023 Apr 6;10:1071741. doi: 10.3389/fmed.2023.1071741. eCollection 2023.
The Surviving Sepsis Campaign suggested preferential resuscitation with balanced crystalloids, such as Lactated Ringer's (LR), although the level of recommendation was weak, and the quality of evidence was low. Past studies reported an association of unbalanced solutions, such as normal saline (NS), with increased AKI risks, metabolic acidosis, and prolonged ICU stay, although some of the findings are conflicting. We have compared the outcomes with the preferential use of normal saline vs. ringer's lactate in a cohort of sepsis patients.
We performed a retrospective cohort analysis of patients visiting the ED of 19 different Mayo Clinic sites between August 2018 to November 2020 with sepsis and receiving at least 30 mL/kg fluid in the first 6 h. Patients were divided into two cohorts based on the type of resuscitation fluid (LR vs. NS) and propensity-matching was done based on clinical characteristics as well as fluid amount (with 5 ml/kg). Single variable logistic regression (categorical outcomes) and Cox proportional hazards regression models were used to compare the primary and secondary outcomes between the 2 groups.
Out of 2022 patients meeting our inclusion criteria; 1,428 (70.6%) received NS, and 594 (29.4%) received LR as the predominant fluid (>30 mL/kg). Patients receiving predominantly NS were more likely to be male and older in age. The LR cohort had a higher BMI, lactate level and incidence of septic shock. Propensity-matched analysis did not show a difference in 30-day and in-hospital mortality rate, mechanical ventilation, oxygen therapy, or CRRT requirement. We did observe longer hospital LOS in the LR group (median 5 vs. 4 days, = 0.047 and higher requirement for ICU post-admission (OR: 0.70; 95% CI: 0.51-0.96; = 0.026) in the NS group. However, these did not remain statistically significant after adjustment for multiple testing.
In our matched cohort, we did not show any statistically significant difference in mortality rates, hospital LOS, ICU admission after diagnosis, mechanical ventilation, oxygen therapy and RRT between sepsis patients receiving lactated ringers and normal saline as predominant resuscitation fluid. Further large-scale prospective studies are needed to solidify the current guidelines on the use of balanced crystalloids.
拯救脓毒症运动建议优先使用平衡晶体液进行复苏，如乳酸林格氏液（LR），尽管推荐级别较低，证据质量也不高。过去的研究报告称，诸如生理盐水（NS）等非平衡溶液与急性肾损伤风险增加、代谢性酸中毒及重症监护病房（ICU）住院时间延长有关，尽管部分研究结果存在矛盾。我们比较了脓毒症患者队列中优先使用生理盐水与乳酸林格氏液的结局。
我们对2018年8月至2020年11月期间前往19个不同梅奥诊所急诊科且患有脓毒症并在前6小时内接受至少30 mL/kg液体的患者进行了回顾性队列分析。根据复苏液体类型（LR与NS）将患者分为两个队列，并根据临床特征以及液体量（相差5 ml/kg）进行倾向匹配。使用单变量逻辑回归（分类结局）和Cox比例风险回归模型比较两组之间的主要和次要结局。
在符合我们纳入标准的2022例患者中，1428例（70.6%）接受了NS，594例（29.4%）接受了LR作为主要液体（>30 mL/kg）。主要接受NS的患者更可能为男性且年龄较大。LR队列的体重指数、乳酸水平及感染性休克发生率更高。倾向匹配分析未显示30天和住院死亡率、机械通气、氧疗或连续性肾脏替代治疗（CRRT）需求方面存在差异。我们确实观察到LR组的住院时间更长（中位数5天对4天，P = 0.047），NS组ICU入院后需求更高（比值比：0.70；95%置信区间：0.51 - 0.96；P = 0.026）。然而，在进行多重检验调整后，这些差异不再具有统计学意义。
在我们的匹配队列中，接受乳酸林格氏液和生理盐水作为主要复苏液体的脓毒症患者在死亡率、住院时间、诊断后ICU入院、机械通气、氧疗和肾脏替代治疗方面未显示出任何统计学上的显著差异。需要进一步的大规模前瞻性研究来巩固当前关于使用平衡晶体液的指南。
