液体超负荷与脓毒症患者死亡风险的剂量-反应关系研究  

Dose-response association between fluid overload and hospital mortality in patients with sepsis

作　　者：王美平 席修明[2] 朱波[2] 娄然 姜琦[2] 何燕 姜利 Wang Meiping;Xi Xiuming;Zhu Bo;Lou Ran;Jiang Qi;He Yan;Jiang Li(Department of Critical Care Medicine,Xuanwu Hospital,Capital Medical University,Beijing 100053,China;Department of Critical Care Medicine,Fuxing Hospital,Capital Medical University,Beijing 100038,China;Department of Epidemiology and Health Statistics,School of Public Health,Capital Medical University,Beijing 100069,China)

机构地区：[1]首都医科大学宣武医院重症医学科,北京100053 [2]首都医科大学附属复兴医院重症医学科,北京100038 [3]首都医科大学公共卫生学院流行病与卫生统计学系,北京100069

出　　处：《中华内科杂志》2023年第5期513-519,共7页Chinese Journal of Internal Medicine

基　　金：国家科技支撑计划项目(2012BAI11B05);国家临床重点专科建设项目(2021-451);北京市重大疫情防治重点专科项目(2021-135)。

摘　　要：目的探讨液体超负荷与脓毒症患者住院死亡风险的剂量-反应关系。方法多中心前瞻性队列研究。对象来源于2013年1月至2014年8月中国危重症患者脓毒症调查,选年龄≥18岁、入住ICU时间≥3 d的脓毒症患者,计算患者入组后前3天每日液体平衡、累积液体平衡、液体超负荷、最大液体超负荷(MFO)。根据MFO将研究对象分为MFO<5%L/kg者、MFO 5%~10%L/kg者及MFO≥10%L/kg者。采用Kaplan-Meier生存曲线比较不同MFO者住院累积存活率,采用带有限制性立方样条函数的多因素Cox回归模型分析MFO与脓毒症患者住院死亡风险的关系。结果2070例脓毒症患者纳入本研究,男性1339例,女性731例,年龄(62.6±17.9)岁。1374例(66.4%)患者存活,696例(33.6%)患者住院期间死亡。MFO<5%L/kg者968例(46.8%),MFO 5%~10%L/kg者530例(25.6%),MFO≥10%L/kg者572例(27.6%)。死亡者入ICU前3天的液体总入量[7642.0(2874.3,13639.5)ml]高于存活者[5738.0(1489.0,7153.5)ml],液体总出量[4086.0(1367.0,6354.5)ml]低于存活者[6130.0(2046.0,11762.0)ml]。随着住ICU时间延长,患者累积生存率逐渐降低,MFO<5%者为74.9%(725/968),MFO 5%~10%L/kg者为67.7%(359/530),MFO≥10%L/kg者为51.6%(295/572),差异有统计学意义(P<0.001)。与MFO<5%L/kg者比,MFO≥10%L/kg者住院死亡风险增加(HR=1.49,95%CI 1.28~1.73)。MFO每增加1%L/kg,患者住院死亡风险增加7%(HR=1.07,95%CI 1.05~1.09)。MFO与住院死亡风险呈“J”型剂量-反应关系,MFO为4.1%L/kg,患者住院死亡风险最低。结论液体超负荷与脓毒症患者住院死亡风险存在“J”型曲线关系,住院死亡风险最低点为MFO为4.1%L/kg,累积液体量高于或低于“最适”液体平衡,脓毒症患者死亡风险均会增加。Objective To investigate dose-response associations between fluid overload(FO)and hospital mortality in patients with sepsis.Methods The current cohort study was prospective and multicenter.Data were derived from the China Critical Care Sepsis Trial,which was conducted from January 2013 to August 2014.Patients aged≥18 years who were admitted to intensive care units(ICUs)for at least 3 days were included.Fluid input/output,fluid balance,fluid overload(FO),and maximum FO(MFO)were calculated during the first 3 days of ICU admission.The patients were divided into three groups based on MFO values:MFO<5%L/kg,MFO 5%-10%L/kg,and MFO≥10%L/kg.Kaplan-Meier analysis was used to predict time to death in hospital in the three groups.Associations between MFO and in-hospital mortality were evaluated via multivariable Cox regression models with restricted cubic splines.Results A total of 2070 patients were included in the study,of which 1339 were male and 731 were female,and the mean age was(62.6±17.9)years.Of 696(33.6%)who died in hospital,968(46.8%)were in the MFO<5%L/kg group,530(25.6%)were in the MFO 5%-10%L/kg group,and 572(27.6%)were in the MFO≥10%L/kg group.Deceased patients had significantly higher fluid input than surviving patients during the first 3 days[7642.0(2874.3,13639.5)ml vs.5738.0(1489.0,7153.5)ml],and lower fluid output[4086.0(1367.0,6354.5)ml vs.6130.0(2046.0,11762.0)ml].The cumulative survival rates in the three groups gradually decreased with length of ICU stay,and they were 74.9%(725/968)in the MFO<5%L/kg group,67.7%(359/530)in the MFO 5%-10%L/kg group,and 51.6%(295/572)in the MFO≥10%L/kg group.Compared with the MFO<5%L/kg group,the MFO≥10%L/kg group had a 49%increased risk of inhospital mortality(HR=1.49,95%CI 1.28-1.73).For each 1%L/kg increase in MFO,the risk of in-hospital mortality increased by 7%(HR=1.07,95%CI 1.05-1.09).There was a“J-shaped”non-linear association between MFO and in-hospital mortality with a nadir of 4.1%L/kg.Conclusion Higher and lower optimum fluid balance levels wer

关 键 词：脓毒症 液体超负荷 剂量-反应关系 医院死亡率 

分 类 号：R459.7[医药卫生—急诊医学]