CCM:中度静脉液体复苏与脓毒症死亡率降低相关

Abstract

Objectives: Significant practice variation exists in the amount of resuscitative IV fluid given to patients with sepsis. Current research suggests equipoise between a tightly restrictive or more liberal strategy but data is lacking on a wider range of resuscitation practices. We sought to examine the relationship between a wide range of fluid resuscitation practices and sepsis mortality and then identify the primary driver of this practice variation.

目的：在给予脓毒症患者复苏性静脉输液的量上存在显著的实践差异。当前研究表明，严格限制或更自由的策略之间存在平衡，但缺乏关于更广泛复苏实践的数据。我们试图检查广泛的液体复苏实践与脓毒症死亡率之间的关系，然后确定这种实践差异的主要驱动因素。

Design: Retrospective analysis of the Premier Healthcare Database.

设计：对Premier Healthcare数据库进行回顾性分析。

Setting: Six hundred twelve U.S. hospitals.

环境：612家美国医院。

Patients: Patients with sepsis and septic shock admitted from the emergency department to the ICU from January 1, 2016, to December 31, 2019.

患者：2016年1月1日至2019年12月31日，从急诊科入院至ICU的脓毒症和脓毒性休克患者。

Interventions: The volume of resuscitative IV fluid administered before the end of hospital day- 1 and mortality.

干预措施：在医院第1天结束前给予的复苏性静脉输液量和死亡率。

Measurements and main results: In total, 190,682 patients with sepsis and septic shock were included in the analysis. Based upon patient characteristics and illness severity, we predicted that physicians should prescribe patients with sepsis a narrow mean range of IV fluid (95% range, 3.6-4.5 L). Instead, we observed wide variation in the mean IV fluids administered (95% range, 1.7-7.4 L). After splitting the patients into five groups based upon attending physician practice, we observed patients in the moderate group (4.0 L; interquartile range [IQR], 2.4-5.1 L) experienced a 2.5% reduction in risk-adjusted mortality compared with either the very low (1.6 L; IQR, 1.0-2.5 L) or very high (6.1 L; IQR, 4.0-9.0 L) fluid groups p < 0.01). An analysis of within- and between-hospital IV fluid resuscitation practices showed that physician variation within hospitals instead of practice differences between hospitals accounts for the observed variation.

测量和主要结果：总共包括了190,682名脓毒症和脓毒性休克患者。根据患者特征和疾病严重程度，我们预测医生应该为脓毒症患者开出一个狭窄的平均静脉输液范围（95%范围，3.6-4.5升）。相反，我们观察到平均静脉输液量存在广泛的变异（95%范围，1.7-7.4升）。将患者根据主治医生的实践分为五组后，我们观察到中等组（4.0升；四分位间距[IQR]，2.4-5.1升）的患者与非常低（1.6升；IQR，1.0-2.5升）或非常高（6.1升；IQR，4.0-9.0升）的液体组相比，风险调整后的死亡率降低了2.5%（p < 0.01）。对医院内外静脉输液复苏实践的分析表明，医院内部医生的变异而不是医院之间的实践差异，解释了观察到的变异。

Conclusions: Individual physician practice drives excess variation in the amount of IV fluid given to patients with sepsis. A moderate approach to IV fluid resuscitation is associated with decreased sepsis mortality and should be tested in future randomized controlled trials. 

结论：个别医生的实践导致了给予脓毒症患者静脉输液量的过度变异。适度的静脉输液复苏方法与降低脓毒症死亡率相关，并应在未来的随机对照试验中进行测试。