有心力衰竭和无心力衰竭的败血症患者早期静脉输液量与住院结果之间的关系:一项回顾性队列研究

Q4 Medicine
Critical care explorations Pub Date : 2024-04-26 eCollection Date: 2024-05-01 DOI:10.1097/CCE.0000000000001082
Alexander J Beagle, Priya A Prasad, Colin C Hubbard, Sven Walderich, Sandra Oreper, Yumiko Abe-Jones, Margaret C Fang, Kirsten N Kangelaris
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引用次数: 0

摘要

目的评估伴有或不伴有心力衰竭(HF)的脓毒症患者早期静脉输液量与住院预后(包括院内死亡或出院后接受临终关怀)之间的关系:这是一项回顾性队列研究,采用限制性三次样条逻辑回归评估输液量与预后之间的非线性关系,根据心衰状态进行分层,并对前 6 小时接受特定输液量的倾向进行调整。还进行了 ICU 亚组分析。对幸存者使用血管加压素、机械通气和住院时间的次要结果进行了评估:背景:一家城市大学附属医院:2012年至2021年期间,急诊科共收治了9613名符合基于电子病历的败血症-3标准的成年患者。干预措施:无:干预措施:无:共有 1449 例高血压患者入院。无心房颤动患者的输液量与死亡或出院安宁疗护之间呈非线性关系,而心房颤动患者的输液量与死亡或出院安宁疗护之间呈近似线性关系。与 30-45 毫升/千克的输液量相比,前 6 小时内接受 0-15 毫升/千克输液的高血压患者死亡或出院安宁疗护的几率较低(几率比 = 0.61;95% CI,0.41-0.90;p = 0.01),但非高血压患者则无明显差异。在重症监护室入院和一些次要结果中也发现了类似的模式。非心房颤动患者的输液量大于 15-30 毫升/千克,入住 ICU 的非心房颤动患者的输液量大于 30-45 毫升/千克,均与预后改善无关:符合《败血症-3》标准的心房颤动患者和非心房颤动患者之间,早期液体复苏显示出不同的潜在危害和获益模式。限制性三次样条分析强调了考虑非线性液体结果关系的重要性,并确定了潜在的收益递减点(所有无 HF 患者为 15-30 mL/kg,入住 ICU 患者为 30-45 mL/kg)。接受少于 15 毫升/千克的输液与心房颤动患者更好的预后有关,这表明小容量输液可能适合特定患者。未来的研究可能会受益于对非线性液体-结果关联的调查以及对其他疾病(如心房颤动)的关注。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Associations Between Volume of Early Intravenous Fluid and Hospital Outcomes in Septic Patients With and Without Heart Failure: A Retrospective Cohort Study.

Objectives: To evaluate the relationship between early IV fluid volume and hospital outcomes, including death in-hospital or discharge to hospice, in septic patients with and without heart failure (HF).

Design: A retrospective cohort study using logistic regression with restricted cubic splines to assess for nonlinear relationships between fluid volume and outcomes, stratified by HF status and adjusted for propensity to receive a given fluid volume in the first 6 hours. An ICU subgroup analysis was performed. Secondary outcomes of vasopressor use, mechanical ventilation, and length of stay in survivors were assessed.

Setting: An urban university-based hospital.

Patients: A total of 9613 adult patients were admitted from the emergency department from 2012 to 2021 that met electronic health record-based Sepsis-3 criteria. Preexisting HF diagnosis was identified by the International Classification of Diseases codes.

Interventions: None.

Measurements and main results: There were 1449 admissions from patients with HF. The relationship between fluid volume and death or discharge to hospice was nonlinear in patients without HF, and approximately linear in patients with HF. Receiving 0-15 mL/kg in the first 6 hours was associated with lower likelihood of death or discharge to hospice compared with 30-45 mL/kg (odds ratio = 0.61; 95% CI, 0.41-0.90; p = 0.01) in HF patients, but no significant difference for non-HF patients. A similar pattern was identified in ICU admissions and some secondary outcomes. Volumes larger than 15-30 mL/kg for non-HF patients and 30-45 mL/kg for ICU-admitted non-HF patients were not associated with improved outcomes.

Conclusions: Early fluid resuscitation showed distinct patterns of potential harm and benefit between patients with and without HF who met Sepsis-3 criteria. Restricted cubic splines analysis highlighted the importance of considering nonlinear fluid outcomes relationships and identified potential points of diminishing returns (15-30 mL/kg across all patients without HF and 30-45 mL/kg when admitted to the ICU). Receiving less than 15 mL/kg was associated with better outcomes in HF patients, suggesting small volumes may be appropriate in select patients. Future studies may benefit from investigating nonlinear fluid-outcome associations and a focus on other conditions like HF.

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