Gattinoni L, Brazzi L, Pelosi P, Latini R, Tognoni G, Pesenti A, Fumagalli R
Istituto di Anestesia e Rianimazione, Università di Milano, Ospedale Maggiore di Milano, Italy.
N Engl J Med. 1995 Oct 19;333(16):1025-32. doi: 10.1056/NEJM199510193331601.
Hemodynamic therapy to raise the cardiac index and oxygen delivery to supranormal may improve outcomes in critically ill patients. We studied whether increasing the cardiac index to a supranormal level (cardiac-index group) or increasing mixed venous oxygen saturation to a normal level (oxygen-saturation group) would decrease morbidity and mortality among critically ill patients, as compared with a control group in which the target was a normal cardiac index.
A total of 10,726 patients in 56 intensive care units were screened, among whom 762 patients belonging to predefined diagnostic categories with acute physiology scores of 11 or higher were randomly assigned to the three groups (252 to the control group, 253 to the cardiac-index group, and 257 to the oxygen-saturation group).
The hemodynamic targets were reached by 94.3 percent of the control group, 44.9 percent of the cardiac-index group, and 66.7 percent of the oxygen-saturation group (P < 0.001). Mortality was 48.4, 48.6, and 52.1 percent, respectively (P = 0.638), up to the time of discharge from the intensive care unit and 62.3, 61.7, and 63.8 percent (P = 0.875) at six months. Among patients who survived, the number of dysfunctional organs and the length of the stay in the intensive care unit were similar in the three groups. No differences in mortality among the three groups were found for any diagnostic category. A subgroup analysis of the patients in whom hemodynamic targets were reached revealed similar mortality rates: 44.8, 40.4, and 39.0 percent, respectively (P = 0.478).
Hemodynamic therapy aimed at achieving supranormal values for the cardiac index or normal values for mixed venous oxygen saturation does not reduce morbidity or mortality among critically ill patients.
将心脏指数和氧输送提高到超常水平的血流动力学治疗可能改善危重症患者的预后。我们研究了与目标为正常心脏指数的对照组相比，将心脏指数提高到超常水平（心脏指数组）或使混合静脉血氧饱和度提高到正常水平（血氧饱和度组）是否会降低危重症患者的发病率和死亡率。
对56个重症监护病房的10726例患者进行了筛查，其中762例属于预定义诊断类别且急性生理学评分在11分及以上的患者被随机分为三组（252例进入对照组，253例进入心脏指数组，257例进入血氧饱和度组）。
对照组94.3%、心脏指数组44.9%、血氧饱和度组66.7%达到血流动力学目标（P<0.001）。直至从重症监护病房出院时，死亡率分别为48.4%、48.6%和52.1%（P = 0.638），6个月时分别为62.3%、61.7%和63.8%（P = 0.875）。在存活患者中，三组的功能障碍器官数量和在重症监护病房的住院时间相似。在任何诊断类别中，三组之间均未发现死亡率存在差异。对达到血流动力学目标的患者进行亚组分析显示死亡率相似：分别为44.8%、40.4%和39.0%（P = 0.478）。
旨在使心脏指数达到超常值或使混合静脉血氧饱和度达到正常值的血流动力学治疗并不能降低危重症患者的发病率或死亡率。
