急诊腹部手术中的目标导向液体治疗:一项随机多中心试验

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急诊腹部手术中的目标导向液体治疗:

一项随机多中心试验

贵州医科大学 麻醉与心脏电生理课题组

翻译：牛振瑛    编辑：潘志军    审校：曹莹

背景   

超过50%的患者在急诊胃肠手术后出现重大并发症。静脉输液治疗是一种挽救生命的治疗方法，但是缺乏证据来指导何种静脉输液策略能获得最好的结果。我们假设，与标准的静脉输液治疗(STD组)相比，手术期间目标导向的液体治疗(GDT组)可降低胃肠大手术患者发生主要并发症或死亡的风险。

方法   

在一项随机、评估者盲、双臂、多中心试验中，我们纳入了312例患有胃肠道梗阻或穿孔的成年患者。GDT组的患者接受静脉输液，直至接近最大的心脏每搏量。STD组患者根据最佳临床实践接受静脉输液。术后目标为0-2L液体平衡。主要终点为主要并发症或90天内死亡的综合结果。次要结果为重症监护时间、呼吸机使用时间、透析时间、住院时间和轻微并发症发生情况。

结果   

在改进的意向治疗分析中，我们发现两组之间的主要结果没有差异：45 (30%) (GDT组)vs 39 (25%) (STD组)(优势比=1.24;95%CI，0.75-2.05;P=0.40)。GDT组的住院时间更长:中位数(四分位间距)，7天 (4-12) vs 6天(4-8.5) (P=0.04);其它观察指标没有发现差异。

结论

与压力引导的静脉输液治疗(STD组，确保MAP > 65mmhg，尿量>0.5 ml kg-1h-1。)相比，流量引导的液体治疗(GDT组，SV的增幅小于10%)不能改善肠梗阻或胃肠道穿孔术后的预后，但可能延长住院时间。

        原始文献来源

Aaen AA, et al. Goal-directed fluid therapy in emergency abdominal surgery: a randomised multicentre trial[J].Br J Anaesth.2021Oct;127(4):521-531.doi:10.1016/j.bja.2021.06.031.  Epub 2021 Aug 11.

     英文原文

Goal-directed fluid therapy in emergency abdominal surgery: a randomised multicentre trial

Background 

More than 50% of patients have a major complication after emergency gastrointestinal surgery. Intravenous(i.v.) fluid therapy is a life-saving part of treatment, but evidence to guide what i.v. fluid strategy results in the best outcome is lacking. We hypothesised that goal-directed fluid therapy during surgery (GDT group) reduces the risk of major complications or death in patients undergoing major emergency gastrointestinal surgery compared with standard i.v. fluid therapy (STD group).

Methods 

In a randomised, assessor-blinded, two-arm, multicentre trial, we included 312 adult patients with gastroin-testinal obstruction or perforation. Patients in the GDT group received i.v. fluid to near-maximal stroke volume. Patients in the STD group received i.v. fluid following best clinical practice. Postoperative target was 0e2 L fluid balance. The primary outcome was a composite of major complications or death within 90 days. Secondary outcomes were time in intensive care, time on ventilator, time in dialysis, hospital stay, and minor complications.

Results 

In a modified intention-to-treat analysis, we found no difference in the primary outcome between groups: 45(30%) (GDT group) vs 39 (25%) (STD group) (odds ratio=1.24; 95% confidence interval, 0.75e2.05; P=0.40). Hospital stay was

longer in the GDT group: median (inter-quartile range), 7 (4-12) vs 6 days (4-8.5) (P=0.04); no other differences were found.

Conclusions 

Compared with pressure-guided i.v. fluid therapy (STD group), flow-guided fluid therapy to near-maximal stroke volume (GDT group) did not improve the outcome after surgery for bowel obstruction or gastrointestinal perforation but may have prolonged hospital stay.