عنوان مقاله
تعادل مثبت مایعات به عنوان یک عامل پیش بینی کننده مرگ و آسیب حاد کلیه ها در سپسیس (عفونت) شدید و شوک سپتیک (عفونی)
فهرست مطالب
مقدمه
روش ها
نتایج
بحث
نتیجه گیری
بخشی از مقاله
روش ها
این یک تجزیه و تحلیل گذشته نگر، از یک مطالعه گروهی آینده نگر منتشر شده قبلی می باشد که در یک ICU 35 تخته در بیمارستان های آموزشی دانشگاه انجام شد. ما بیماران مسن تر از 18 سال سن را همراه با تشخیص سپسیس شدید یا شوک سپتیک، مطابق با تعاریف فعلی شرکت دادیم. به طور خلاصه، اختلال عملکرد ارگان ناشی از سپسیس، یکی از موارد زیر در نظر گرفته شد:
کلمات کلیدی:
Positive fluid balance as a prognostic factor for mortality and acute kidney injury in severe sepsis and septic shock☆ Fernando Saes Vilaça de Oliveira, MD, Flavio Geraldo Resende Freitas, MD, PhD, Elaine Maria Ferreira, RN, Isac de Castro, PhD, Antonio Toneti Bafi, MD, Luciano Cesar Pontes de Azevedo, MD, PhD, Flavia Ribeiro Machado, MD, PhD ⁎ Anesthesiology, Pain and Intensive Care Department, Federal University of São Paulo–UNIFESP, São Paulo, Brazil article info abstract Keywords: Severe sepsis Fluid balance Mortality Purpose: The purpose of this study is to assess whether late positive fluid balances are associated with acute kidney injury and mortality in severe sepsis and septic shock. Methods: In this retrospective study, fluid balances were calculated at 3 different time points: the onset of organ dysfunction attributed to sepsis, sepsis diagnosis, and vasopressors initiation. Data were analyzed in logistic regression models for mortality and acute kidney injury as outcomes. Results: We included 116 patients. A RIFLE score F, diuresis less than 0.9 L from the second day after the first organ dysfunction, and fluid balance more than 3 L between the 24th and the 48th hour after diagnosis were independently associated with higher mortality, whereas in the subgroup with shock, only the latter parameter and diuresis less than 0.85 L on the first day of shock were independent risk factors. After adjusting for age, creatinine more than 1.2 mg/dL, a nonrenal Sequential Organ Failure Assessment greater than or equal to 7.5 on the first day and urine output less than 1.3 L on the first day after organ dysfunction were independent risk factors for RIFLE F. No relationship was found between fluid balance and acute kidney injury. Conclusion: Late positive fluid balance is an independent risk factor for mortality in severe sepsis. Positive fluid balances are not associated with either protection against or risk for acute kidney injury. © 2014 Elsevier Inc. All rights reserved. 1. Introduction Severe sepsis and septic shock are among the most challenging conditions in medicine. Despite major advances, these syndromes remain major causes of death in intensive care units (ICUs), with an increasing incidence as seen in observational studies [1,2]. Since the landmark Early Goal-directed Therapy study, several recommendations have been issued concerning fluid management, mainly consisting of large-volume fluid resuscitation, especially during the first 6 hours after sepsis onset [3,4]. It is widely acknowledged that a lack of adequate fluid resuscitation during these crucial first hours can result in tissue hypoperfusion and associated hazardous consequences [5,6]. In contrast, liberal fluid resuscitation also results in large fluid balances, and it is uncertain how long this strategy should be maintained. Recent evidence also suggested that fluids in excess can have adverse effects and can worsen outcomes [6]. A large randomized trial of patients with acute lung injury showed that a restrictive fluid management strategy resulted in fewer days on mechanical ventilation [7]. Positive fluid balances have been associated with higher morbidity and mortality in several observational studies with different clinical contexts, including septic shock [8-16]. It is also a matter of debate how fluid management influences outcomes regarding acute kidney injury. Oliguria is a common trigger of fluid administration, and it is not clear whether fluid loading is effective in protecting the kidneys from failing. There are observational data showing that positive fluid balances might not be protective against, and might even be associated with, worse outcomes [8,14,17]. Therefore, we hypothesized that large-volume resuscitation, resulting in positive fluid balances after the first 6 hours from the onset of the disease, would be associated with mortality in severe sepsis and septic patients. We also tested the hypothesis that a positive fluid balance would not be protective against acute kidney injury. 2. Methods This was a retrospective analysis of a previously published prospective cohort study conducted in a 35-bed ICU at a university teaching hospital [18]. We included patients older than 18 years old with diagnoses of severe sepsis or septic shock, in accordance with the current definitions. Briefly, sepsis-induced organ dysfunction was considered one of the following: hypotension, PaO2/oxygen inspiratory fraction (FiO2) ratio less than or equal to 300, lactate level greater than or Journal of Critical Care 30 (2015) 97–101 ☆ The authors declare that they have no conflict of interest. ⁎ Corresponding author. Departamento de Anestesiologia, Dor e Terapia Intensiva. Universidade Federal de São Paulo, Rua Napoleão de Barros 715-5° andar. São Paulo-SP, Brazil, 04024-900. E-mail address: frmachado@unifesp.br (F.R. Machado). http://dx.doi.org/10.1016/j.jcrc.2014.09.002 0883-9441/© 2014 Elsevier Inc. All rights reserved.
