晶体平衡液与生理盐水用于非危重患者的比较
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Balanced Crystalloids versus Saline in Noncritically Ill Adults
背景与目的
晶体平衡液和生理盐水的临床效果比较尚不确定，特别是在重症监护室（ICU）外的非危重病人中的使用。
方 法
我们进行了一项单中心、实用性、多交叉试验，比较了晶体平衡液（乳酸林格氏液或复方电解质溶液）与生理盐水用于急诊室内接受静脉输液治疗并随后在ICU外住院的成年患者中的差异。急诊室使用的晶体类型按月分配给每位患者，在为期16个月的试验中，整个急诊室每月都要将晶体平衡液和生理盐水互换。主要结局是门诊治疗天数（离院后28天内的存活天数）。次要结局包括30天内肾脏发生严重不良事件的综合——任何原因引起死亡、新肾替代治疗或持续性肾功能不全（定义为肌酐水平升高至基线水平的200%以上）——在出院时或出院30天内进行检查，以先发生者为准。
结 果
共有13347名患者被纳入研究，急诊室内输注晶体的平均体积为1079ml，且88.3%的患者仅接受指定的晶体。晶体平衡液组和生理盐水组的门诊治疗天数无差异（中位数：每组25天；晶体平衡液组校正OR：0.98；95%CI：0.92-1.04；P=0.41）。与生理盐水组相比，晶体平衡液组导致的30天内肾脏主要不良事件发生率较低（4.7% vs 5.6%；校正OR：0.82；95%CI：0.70-0.95；P=0.01）。
结 论
在急诊室接受静脉输液治疗的非危重患者中，使用晶体平衡液和生理盐水治疗的门诊治疗天数无差异。
原始文献摘要
Self WH, Semler MW, Wanderer JP, et al.Balanced Crystalloids versus Saline in Noncritically Ill Adults.[J]. N Engl J Med. 2019,378(9):819-828. doi: 10.1056/NEJMoa1711586.
BACKGROUND—Comparative clinical effects of balanced crystalloids and saline are uncertain, particularly in noncritically ill patients cared for outside an intensive care unit (ICU).
METHODS—We conducted a single-center, pragmatic, multiple-crossover trial comparing balanced crystalloids (lactated Ringer’s solution or Plasma-Lyte A) with saline among adults who were treated with intravenous crystalloids in the emergency department and were subsequently hospitalized outside an ICU. The type of crystalloid that was administered in the emergency department was assigned to each patient on the basis of calendar month, with the entire emergency department crossing over between balanced crystalloids and saline monthly during the 16-month trial. The primary outcome was hospital-free days (days alive after discharge before day 28). Secondary outcomes included major adverse kidney events within 30 days — a composite of death from any cause, new renal-replacement therapy, or persistent renal dysfunction (defined as an elevation of the creatinine level to ≥200% of baseline) — all censored at hospital discharge or 30 days, whichever occurred first.
RESULTS—A total of 13,347 patients were enrolled, with a median crystalloid volume administered in the emergency department of 1079 ml and 88.3% of the patients exclusively receiving the assigned crystalloid. The number of hospital-free days did not differ between the balanced-crystalloids and saline groups (median, 25 days in each group; adjusted odds ratio with balanced crystalloids, 0.98; 95% confidence interval [CI], 0.92 to 1.04; P = 0.41). Balanced crystalloids resulted in a lower incidence of major adverse kidney events within 30 days than saline (4.7% vs. 5.6%; adjusted odds ratio, 0.82; 95% CI, 0.70 to 0.95; P = 0.01).
CONCLUSIONS—Among noncritically ill adults treated with intravenous fluids in the emergency department, there was no difference in hospital-free days between treatment with balanced crystalloids and treatment with saline.
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贵州医科大学高鸿教授课题组
翻译：冯玉蓉 编辑：冯玉蓉 审校：王贵龙