Division of Pulmonary Critical Care, Kaiser Permanente, Modesto, CA.
Division of Pulmonary, Critical Care, and Sleep Medicine, Warren Alpert Medical School of Brown University, Providence, RI.
Crit Care Med. 2024 Nov 1;52(11):e557-e567. doi: 10.1097/CCM.0000000000006394. Epub 2024 Aug 23.
Significant practice variation exists in the amount of resuscitative IV fluid given to patients with sepsis. Current research suggests equipoise between a tightly restrictive or more liberal strategy but data is lacking on a wider range of resuscitation practices. We sought to examine the relationship between a wide range of fluid resuscitation practices and sepsis mortality and then identify the primary driver of this practice variation.
Retrospective analysis of the Premier Healthcare Database.
Six hundred twelve U.S. hospitals.
Patients with sepsis and septic shock admitted from the emergency department to the ICU from January 1, 2016, to December 31, 2019.
The volume of resuscitative IV fluid administered before the end of hospital day- 1 and mortality.
In total, 190,682 patients with sepsis and septic shock were included in the analysis. Based upon patient characteristics and illness severity, we predicted that physicians should prescribe patients with sepsis a narrow mean range of IV fluid (95% range, 3.6-4.5 L). Instead, we observed wide variation in the mean IV fluids administered (95% range, 1.7-7.4 L). After splitting the patients into five groups based upon attending physician practice, we observed patients in the moderate group (4.0 L; interquartile range [IQR], 2.4-5.1 L) experienced a 2.5% reduction in risk-adjusted mortality compared with either the very low (1.6 L; IQR, 1.0-2.5 L) or very high (6.1 L; IQR, 4.0-9.0 L) fluid groups p < 0.01). An analysis of within- and between-hospital IV fluid resuscitation practices showed that physician variation within hospitals instead of practice differences between hospitals accounts for the observed variation.
Individual physician practice drives excess variation in the amount of IV fluid given to patients with sepsis. A moderate approach to IV fluid resuscitation is associated with decreased sepsis mortality and should be tested in future randomized controlled trials.
在给予脓毒症患者复苏性静脉补液量方面，存在显著的实践差异。目前的研究表明，在严格限制策略和更宽松策略之间存在平衡，但缺乏更广泛的复苏实践数据。我们旨在研究广泛的液体复苏实践与脓毒症死亡率之间的关系，然后确定这种实践差异的主要驱动因素。
对 Premier Healthcare Database 的回顾性分析。
美国 612 家医院。
2016 年 1 月 1 日至 2019 年 12 月 31 日从急诊室收住 ICU 的脓毒症和脓毒性休克患者。
在住院第 1 天结束前给予的复苏性静脉补液量和死亡率。
共有 190682 例脓毒症和脓毒性休克患者纳入分析。基于患者特征和疾病严重程度，我们预测医生应给脓毒症患者开一个狭窄的平均范围的静脉补液量（95%范围，3.6-4.5L）。相反，我们观察到给予的平均静脉补液量存在广泛的变化（95%范围，1.7-7.4L）。根据主治医生的实践将患者分为五组后，我们发现中度组（4.0L；四分位间距[IQR]，2.4-5.1L）与极低组（1.6L；IQR，1.0-2.5L）或极高组（6.1L；IQR，4.0-9.0L）相比，风险调整后死亡率降低了 2.5%，差异有统计学意义（p<0.01）。对医院内和医院间静脉补液复苏实践的分析表明，医院内医生的变异而不是医院间的实践差异解释了观察到的变异。
个体医生的实践导致给予脓毒症患者的静脉补液量过多。适度的静脉液体复苏方法与降低脓毒症死亡率相关，应在未来的随机对照试验中进行测试。
