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中华卫生应急电子杂志 ›› 2021, Vol. 07 ›› Issue (01) : 18 -25. doi: 10.3877/cma.j.issn.2095-9133.2021.01.004

所属专题: 文献

论著

限制性液体复苏对脓毒症休克患者疗效的meta分析
姜帅宇1, 路晓光2,(), 吴萌萌1   
  1. 1. 116001 辽宁大连,大连大学附属中山医院急诊科;116622 辽宁大连,大连大学研究生院
    2. 116001 辽宁大连,大连大学附属中山医院急诊科
  • 收稿日期:2020-10-26 出版日期:2021-02-18
  • 通信作者: 路晓光
  • 基金资助:
    国家自然科学基金项目(81673801,81473512)

Efficacy of restricted fluid resuscitation in patients with septic shock: a meta analysis

Shuaiyu Jiang1, Xiaoguang Lu2,(), Mengmeng Wu1   

  1. 1. Department of Emergency Medicine, Affiliated Zhongshan Hospital of Dalian University, Dalian 116001, China; Graduate School, Dalian University, Dalian 116622, China
    2. Department of Emergency Medicine, Affiliated Zhongshan Hospital of Dalian University, Dalian 116001, China
  • Received:2020-10-26 Published:2021-02-18
  • Corresponding author: Xiaoguang Lu
引用本文:

姜帅宇, 路晓光, 吴萌萌. 限制性液体复苏对脓毒症休克患者疗效的meta分析[J/OL]. 中华卫生应急电子杂志, 2021, 07(01): 18-25.

Shuaiyu Jiang, Xiaoguang Lu, Mengmeng Wu. Efficacy of restricted fluid resuscitation in patients with septic shock: a meta analysis[J/OL]. Chinese Journal of Hygiene Rescue(Electronic Edition), 2021, 07(01): 18-25.

目的

探究限制性液体复苏对脓毒症休克患者的治疗效果。

方法

计算检索Pubmed、Cochrane Library、Embase、Web of science、中国知网及维普和万方的数据库,搜集有关限制性液体复苏对脓毒症休克患者治疗效果和预后的影响的随机对照试验(RCT),检索时限均为建库至2020年9月30日。由2名研究者独立筛选文献、提取资料并评价纳入研究的偏倚风险后,采用RevMan 5.3软件进行Meta分析。

结果

本文共纳入7个RCT,614例患者。Meta分析结果显示,限制液体复苏组和常规足量液体复苏组相比病死率降低,(OR=0.65,95%CI=0.43~0.98,P<0.05),重症监护病房(ICU)住院时间(LoS)同样降低,差异有统计学意义[平均差异(MD)=-3.28,95%CI=-4.08~2.49,P<0.05],但急性肾损伤发生率差异无明显统计学意义(OR=0.69,95%CI=0.53~2.26,P>0.05)。

结论

对于脓毒症休克患者与常规足量液体复苏相比,限制性液体复苏的病死率和ICU住院时间都降低,但是虽然液体输入总量减少,急性肾损伤的副作用不良反应却没有改善。总体而言限制性液体复苏,在治疗效果和经济角度都优于常规足量液体复苏,可以根据病情适当选用。

Objective

To investigate the curative effect of restrictive fluid resuscitation therapy in septic shock patients.

Methods

We searched the PubMed, Cochrane Library, Embase, Web of Science, CNKI, VIP and WanFang databases to collect randomized controlled trials (RCT) on the effects of restrictive fluid resuscitation on the treatment and prognosis of patients with septic shock. The search time limit was from the establishment of the database to September 30, 2020. After two researchers independently screened the literature, extracted data, and evaluated the risk of bias in the included studies. RevMan 5.3 software was used for meta-analysis.

Results

Seven studies containing 614 patients with septic shock were analyzed in the meta-analysis. The results showed that the mortality of the group with restricted fluid resuscitation was lower than that of the group with conventional adequate fluid resuscitation (OR=0.65, 95%CI=0.43~0.98, P< 0.05), and the length of stay in the ICU LoS was also lower [mean difference (MD)=-3.28, 95%CI= -4.08~-2.49, P<0.05)]. But there was no statistically difference in the incidence of acute kidney injury (OR=0.69, 95%CI=0.53~2.26; P>0.05).

Conclusion

Compared with conventional adequate fluid resuscitation, restrictive fluid resuscitation in patients with septic shock has reduced mortality and ICU LoS. However, although the total fluid input is decreased, the side effects of acute kidney injury have not ameliorated. In general, it is superior to conventional fluid resuscitation in terms of therapeutic effect and economics, and can be used as clinically needed.

图1 文献筛选流程图
表1 纳入文献特征表
作者 年份 患者特征 实验设计 干预措施 可能造成偏倚的因素 主要结局指标 国家
徐航[13] 2014 严重脓毒症和脓毒症休克患者 单中心随机对照试验 研究组患者在平均动脉压升高至50~ 60 mmHg时,减少液体输入,减慢输液速度,维持平均动脉压在50 mmHg,对照组患者维持平均动脉压70 mmHg 未提及 血流动力学变化 中国
李鹤[14] 2015 脓毒症休克患者 单中心随机对照试验 实验组患者在第1 h输液500~1 000 mL,维持平均动脉压50~70 mmHg。尿量维持在0.5~1 mL/(kg·h)左右。对照组患者在第1小时输注1 000~1 500 mL液体,维持平均动脉压>70 mmHg。尿量维持在1~1.5 mL/(kg·h)左右 未提及 未提及 中国
Hjortrup[15] 2016 重症监护室的脓毒症休克患者 经典随机,平行组,多中心可行性试验 在液体限制组中,只有在出现严重的低灌注的迹象时才允许使用液体复苏,而在标准护理组中,只要循环持续改善,就可以使用静脉液体复苏 常规液体组液体输入量可测到的差异比实验前估计比复苏液体可测差异高两倍以上。因为我们只干预了LFR组复苏液体的使用,所以在限制性总液体输入上没有统计上的显著差异 复苏液体总量 德国和芬兰
王庆霞[16] 2016 成人脓毒症休克患者 单中心随机对照试验 两组均在1 h内接受1 000~1 500 mL复苏液,然后根据患者的血压和尿量调整输液速度。对照组采用常规补液治疗,平均动脉压≥60 mmHg,尿量在1~2 mL /(kg·h)。观察组进行LFR,平均动脉压维持在50~60 mmHg,尿量维持在0.5~1 mL /(kg·h) 未提及 未提及 中国
Macdonald [17] 2018 纳入脓毒症休克患者中93例入院时SOFA评分≥2分;26例患者入院时收缩压<90 mmHg,乳酸≥2 mmol/L,其中22例需要升压药以维持目标平均动脉压 一项前瞻性,随机,开放标签的临床试验 参与者将被随机分为两组,一组是第二次注射1 000 mL液体丸(标准护理),另一组仅注射维持液体 总体病死率为7%,低于预期。可能与收缩压< 100 mmHg纳入标准有关 随机分组后,每个组6 h内总液体量 澳大利亚和新西兰
辛邵斌[18] 2018 脓毒症休克首发患者 多中心,前瞻性,随机和对照研究 LFR试验组第一次复苏时每小时输注1 000~ 1 500 mL液体。对照组患者在6 h内达到中心静脉压8~12 mmHg、收缩压> 90 mmHg、平均动脉压≥60 mmHg、尿量1~1.5 ml·kg -1·h-1、氧分压>70%或二氧化碳分压≥65%的目标 未提及 28 d生存率以及心肝肾功能变化 中国
Corl[19] 2019 2016年11月至2018年2月从急诊科收治重症监护室收治的严重脓毒症和脓毒症休克患者。患者1 000 mL静脉输液后,仍患有难治性低血压(平均动脉压<65 mmHg)或乳酸大于或等于4 mmol/L 前瞻性随机对照试验 在72 h的护理中,患者被随机分配到限制性静脉输液复苏策略(≤60 mL/kg静脉输液)或常规护理。复苏输液包括所有晶体液(生理盐水和乳酸林格液)和维持输液 受样本量限制,我们没有观察到病死率、器官衰竭或不良事件的增加 30 d全因病死率 美国
表2 GRADE证据质量评定
图2 纳入文献质量评价
图3 死亡率森林图
图4 ICU住院时长森林图
图5 AKI森林图
表3 液体输入量
图6 漏斗图
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