乳酸林格氏液与生理盐水对脓毒性休克患者临床疗效的比较

Efficacy of Lactated Ringer's versus Normal Saline in Treating Patients with Septic Shock

目的比较乳酸林格氏液(LR)和生理盐水(NS)对脓毒性休克患者的临床疗效。方法回顾性分析2014年1月至2016年1月在衢州市人民医院ICU治疗的198例因脓毒性休克需液体复苏患者的临床资料,根据所采用的扩容液体分为NS组(n=100)和LR组(n=98)两组,比较两组患者前3 d的试验液体量、其他液体量、血制品量、平均总液体量;治疗前后氧合指数(PO_2/FiO_2)、平均动脉压(MAP)、中心静脉压(CVP)、血浆脑钠肽(BNP);早期目标导向治疗(EGDT)8、24 h复苏达标率,EGDT复苏达标所需时间,28 d死亡人数;其他次要临床结果:包括出血反应、过敏反应、急性肾损伤(AKI)人数,肾脏替代治疗(RRT)人数、电解质情况、ICU住院时间。采用Kaplan-Meier法计算两组患者28 d时的生存率,log-rank检验比较两组患者的生存率。结果两组患者在性别、年龄、体质量、入ICU前各科室患者数、降钙素原水平、脓毒症来源、急性生理学及慢性健康状况Ⅱ评分、AKI人数、白细胞和C反应蛋白水平等基线特征方面差异均无统计学意义(P均>0.05)。NS组患者治疗第1天的血制品用量[(782±357)ml比(606±273)ml;t=2.044,P=0.046]和前3 d平均总液体量[(5470±1078)ml比(5092±929)ml;t=2.640,P=0.009]明显多于LR组;两组患者在试验液体量和其他液体量方面差异均无统计学意义(P均>0.05)。两组患者治疗后的PO_2/FiO_2、MAP、CVP及BNP水平均较补液前显著升高(P均<0.05);治疗前后各时间点两组间的PO_2/FiO_2、MAP、CVP及BNP水平差异则均无统计学意义(P均>0.05)。NS组患者高乳酸血症(86.0%比71.4%,OR:2.457,95%CI:1.202~5.023,P=0.012)和高氯血症(25.0%比13.2%,OR:2.179,95%CI:1.041~4.562,P=0.036)的发生率明显高于LR组患者;两组患者在EGDT8、24 h复苏达标率,EGDT复苏达标所需时间,28 d病死率,AKI比率,RRT人数、高钾血症发生率,ICU住院时间方面差异均无统计学意义(P均>0.05)。Kaplan-Meier生存分析结果显示,两组患者的28 d生存率差异无统计学意义(χ2log-rank=0.012,P=0.911)。结论在脓毒性休克患者进行液体复苏时,使用NS复苏的首日血制品用量和前3 d平均总液体用量明显多于使用LR复苏,高乳酸血症和高氯血症的发生率也明显高于LR复苏。使用NS复苏和LR复苏的28 d生存率没有显著差异。

Objective To compare the clinical efficacy of lactated Ringer＇s（ LR） and normal saline（NS） in treating patients with septic shock. Methods The clinical data of 198 patients with septic shock who received fluid resuscitation in the Intensive Care Unit of Quzhou People＇s Hospital from January 2014 to January2016 were retrospectively analyzed. These patients were divided into NS group（ n = 100） and LR group（ n = 98）according to fluids used. The amounts of trial fluid,other liquids,and blood products and the average total fluid volume were recorded. The oxygenation index（ PO_2/FiO_2）,mean artery pressure（MAP）,central venous pressure（ CVP）,and B-type natriuretic peptide（ BNP） before and after treatment as well as the early goal-directed therapy（ EGDT） 8 h（ EGDT8）,EGDT 24 h recovery rate,EGDT recovery time,28-day mortality rate were compared. Other secondary outcomes including bleeding,allergic reaction,acute kidney injury（ AKI）,venous blood filtration（ RRT） rate,hyperkalemia,and ICU stay were also recorded. The 28-day survival rate was calculated using the Kaplan-Maier method,and the difference in survival rate was compared by log-rank test. Results The two groups showed no significant difference in gender,age,body weight,source of admission to ICU,procalcitonin level,source of sepsis,Acute Physiology and Chronic Health Evaluation Ⅱ score,number of AKI patients,amount of white blood cells,and C-reactive protein level（ all P 〉0. 05）. The amount of blood products on the first day [（782 ± 357） ml vs.（606 ± 273） ml; t = 2. 044,P = 0. 046]and the average total amount of liquid on the first three days [（5470 ± 1078） ml vs.（5092 ± 929） ml; t = 2. 640,P = 0. 009]were significantly higher in NS group than in LR group. The amount of trial fluid and the volumes of other fluids were not significantly different（ both P 〉0. 05）. The PO_2/FiO_2,MAP,CVP,and BNP levels significantly increased after treatment in both groups（ all P 〈0. 05）; however,they were not significantly different between LR group and NS group at different time points before and after treatment（ all P 〉0. 05）. The incidences of hyperlactacidemia（86. 0% vs. 71. 4%,OR： 2. 457,95% CI： 1. 202-5. 023,P = 0. 012） and hyperchloremia（25. 0% vs. 13. 2%,OR： 2. 179,95% CI： 1. 041-4. 562,P = 0. 036） were significantly higher in NS group than in LR group. These two groups showed no significant difference in EGDT8,24 h recovery rate,EGDT recovery time,28-day mortality rate,AKI,RRT rate,hyperkalemia,and ICU stay（ all P 〉0. 05）. KaplanMeier survival analysis showed that the 28-day survival rate was not significantly different（ χ2 log-rank = 0. 012,P = 0. 911）. Conclusion When liquid resuscitation is applied in patients with septic shock,the use of LR can lower blood transfusion requirement on the first day and total liquid dosage on the first three days（ compared with NR）,along with lower incidences of hyperlactacidemia and hyperchloremia,although there was no significant difference in the 28-day mortality rate.