Muscat Neil, Shah Shaneel, Zammit Neill
Vascular Surgery, Manchester Royal Infirmary, Manchester, GBR.
General Surgery, Manchester Foundation Trust, Manchester, GBR.
Cureus. 2024 Sep 30;16(9):e70583. doi: 10.7759/cureus.70583. eCollection 2024 Sep.
Effective fluid management is critical in patients undergoing damage control laparotomy (DCL) for trauma and sepsis. Hypertonic saline (HTS) has been proposed as an alternative to isotonic fluids to enhance primary fascial closure rates and optimize fluid balance. This systematic review and meta-analysis aims to evaluate the efficacy and safety of HTS compared to isotonic fluids in patients undergoing DCL. A comprehensive literature search was conducted across multiple databases up to the 14 of June 2024, identifying studies that compared HTS to isotonic fluids in adult patients undergoing DCL for trauma or sepsis. Eligible studies included randomized controlled trials and observational studies reporting outcomes such as early primary fascial closure (EPFC) rates, time to fascial closure, fluid requirements, electrolyte imbalances, renal function, and mortality. Data extraction and quality assessment were performed independently by two reviewers, and pooled analyses were conducted using fixed-effect models where appropriate. Four studies encompassing 375 patients met the inclusion criteria, with 100 patients receiving HTS and 275 receiving isotonic fluids. HTS administration was associated with a significantly higher EPFC rate compared to isotonic fluids (odds ratio (OR): 0.314; 95% confidence interval (CI): 0.142-0.696; p=0.004). The mean time to fascial closure was also significantly reduced in the HTS group by approximately eight hours (mean difference (MD): 8.007 hours; 95% CI: 5.558-10.596; p<0.001). Patients receiving HTS required significantly less total fluid over 48 hours (MD: 1.055 liters; 95% CI: 0.713-1.398; p<0.001). While HTS use led to higher peak sodium levels (MD: -4.318 mEq/L; 95% CI: -4.702 to -3.934; p<0.001), there were no significant differences in peak creatinine levels, need for inpatient renal replacement therapy, or 28-day mortality between the groups. HTS appears to be effective in improving EPFC rates and reducing both time to closure and overall fluid requirements in patients undergoing DCL for trauma and sepsis. Although associated with higher serum sodium levels, HTS did not increase the risk of renal dysfunction or mortality. These findings suggest that HTS is a safe and efficacious alternative to isotonic fluids in the management of critically ill patients requiring DCL. Further large-scale, randomized controlled trials are warranted to confirm these results and inform clinical guidelines.
对于因创伤和脓毒症接受损伤控制剖腹术（DCL）的患者，有效的液体管理至关重要。高渗盐水（HTS）已被提议作为等渗液体的替代物，以提高一期筋膜闭合率并优化液体平衡。本系统评价和荟萃分析旨在评估在接受DCL的患者中，HTS与等渗液体相比的疗效和安全性。截至2024年6月14日，在多个数据库中进行了全面的文献检索，确定了比较HTS与等渗液体在因创伤或脓毒症接受DCL的成年患者中的研究。符合条件的研究包括随机对照试验和观察性研究，报告的结局指标如早期一期筋膜闭合（EPFC）率、筋膜闭合时间、液体需求量、电解质失衡、肾功能和死亡率。由两名 reviewers 独立进行数据提取和质量评估，并在适当情况下使用固定效应模型进行汇总分析。四项研究共纳入375例患者，符合纳入标准，其中100例患者接受HTS，275例接受等渗液体。与等渗液体相比，HTS给药与显著更高的EPFC率相关（优势比（OR）：0.314；95%置信区间（CI）：0.142 - 0.696；p = 0.004）。HTS组的平均筋膜闭合时间也显著缩短约8小时（平均差（MD）：8.007小时；95% CI：5.558 - 10.596；p < 0.001）。接受HTS的患者在48小时内所需的总液体量显著更少（MD：1.055升；95% CI：0.713 - 1.398；p < 0.001）。虽然使用HTS导致更高的峰值钠水平（MD：-4.318 mEq/L；95% CI：-4.702至-3.934；p < 0.001），但两组之间的峰值肌酐水平、住院期间肾脏替代治疗的需求或28天死亡率没有显著差异。HTS似乎在提高因创伤和脓毒症接受DCL的患者的EPFC率、缩短闭合时间和降低总体液体需求量方面有效。虽然与更高的血清钠水平相关，但HTS并未增加肾功能障碍或死亡的风险。这些发现表明，在管理需要DCL的危重症患者时，HTS是等渗液体的一种安全有效的替代物。需要进一步的大规模随机对照试验来证实这些结果并为临床指南提供依据。
