NEJM:腹部大手术后应选择限制性还是自由液体疗法

2018-06-14 xing.T MedSci原创

由此可见,在并发症风险增加而进行腹部大手术的患者中,限制性液体方案与自由输液方案相比无残疾生存率并未增加,但会导致较高的急性肾损伤发生率。

促进大手术患者早日康复的指南推荐腹部手术后进行限制性静脉输液策略。然而,支持证据是有限的,并且担忧器官灌注受损。

近日,顶级医学期刊NEJM上发表了一篇研究文章,研究人员进行了一项务实的国际试验中,研究人员随机分配3000名因发生并发症的风险增加而接受腹部大手术的患者在术后24小时内接受限制性或自由静脉输液方案。主要结局是1年无残疾生存率。主要的次要结局是30天的急性肾损伤,90天的肾脏替代治疗以及脓毒症并发症、手术部位感染或死亡的复合事件。

在术后24小时内,1490例接受限制性输液的患者静脉液体输入量的中间值为3.7L(四分位范围为2.9-4.9),而自由输液组的1493例患者为6.1L(四分位范围为5-7.4,P<0.001)。限制性输液的患者无残疾生存率为81.9%,自由输液组为82.3%(死亡或残疾的风险比为1.05,95%可信区间为0.88-1.24;P=0.61)。限制性液体组急性肾损伤率为8.6%,自由输液组为5%(P<0.001)。限制性液体组脓毒症并发症或死亡率为21.8%,自由输液组为19.8%(P=0.19);限制性液体组手术部位感染率(16.5% vs. 13.6%,P=0.02)和肾脏替代治疗(0.9% vs. 0.3%,P=0.048)均较高。经多重检验调整后,组间差异并不显著。

由此可见,在并发症风险增加而进行腹部大手术的患者中,限制性液体方案与自由输液方案相比无残疾生存率并未增加,但会导致较高的急性肾损伤发生率。

原始出处:
 
Paul S. Myles,et al.Restrictive versus Liberal Fluid Therapy for Major Abdominal Surgery.N Engl J Med 2018. https://www.nejm.org/doi/full/10.1056/NEJMoa1801601
 
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  2. [GetPortalCommentsPageByObjectIdResponse(id=1721987, encodeId=9f951e21987f1, content=<a href='/topic/show?id=b73f43e1224' target=_blank style='color:#2F92EE;'>#大手术#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=18, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=43712, encryptionId=b73f43e1224, topicName=大手术)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ecc933126179, createdName=Smile2691, createdTime=Wed Nov 07 02:51:00 CST 2018, time=2018-11-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=324085, encodeId=bd25324085bd, content=一起学习学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=45, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/vi_32/TDiaAWyicHgedzX3wKo3qcxudVJib7AfibfvNeufHRF2jG3Bw8MmZyWjIhtBV1mpJI7Sy9n7RcBKK5t3CuOKuOFxkg/0, createdBy=dd702206933, createdName=wzb521zf, createdTime=Thu Jun 14 09:52:26 CST 2018, time=2018-06-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=324066, encodeId=28243240663b, content=学习了.长知识, beContent=null, objectType=article, channel=null, level=null, likeNumber=42, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20220115/46bcf39c32de4aa6b45c5f9d66c8ee77/6cb4a20c55bb4b7691122f47747bfca2.jpg, createdBy=9dad1662329, createdName=1ddf0692m34(暂无匿称), createdTime=Thu Jun 14 09:36:20 CST 2018, time=2018-06-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=324057, encodeId=917e32405e75, content=学了, beContent=null, objectType=article, channel=null, level=null, likeNumber=35, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTKcmgibQ4oCrK7Z6f4CvMcs4k7QUGCkhopcGxvxaBfVciadECSIwaRVttllIOEKumpEaRrq5PoOUxow/0, createdBy=e3bb2081203, createdName=哈哈869, createdTime=Thu Jun 14 08:43:35 CST 2018, time=2018-06-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=324056, encodeId=7f8a3240563d, content=学了, beContent=null, objectType=article, channel=null, level=null, likeNumber=42, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTKcmgibQ4oCrK7Z6f4CvMcs4k7QUGCkhopcGxvxaBfVciadECSIwaRVttllIOEKumpEaRrq5PoOUxow/0, createdBy=e3bb2081203, createdName=哈哈869, createdTime=Thu Jun 14 08:43:32 CST 2018, time=2018-06-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=324048, encodeId=1e793240480a, content=谢谢分享.学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=35, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo6Nx0VGA4QMDzOP8oAgnV4h51EjSfehJ9QxyiaSmw8PB56BhY8KXFSxHCibXrzcy4abrzSibXQPxJ9kzrLcJyhhB8a/0, createdBy=1d3b1672603, createdName=明月清辉, createdTime=Thu Jun 14 08:16:50 CST 2018, time=2018-06-14, status=1, ipAttribution=)]
    2018-06-14 wzb521zf

    一起学习学习

    0

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    2018-06-14 1ddf0692m34(暂无匿称)

    学习了.长知识

    0

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    2018-06-14 哈哈869

    学了

    0

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    2018-06-14 哈哈869

    学了

    0

  6. [GetPortalCommentsPageByObjectIdResponse(id=1721987, encodeId=9f951e21987f1, content=<a href='/topic/show?id=b73f43e1224' target=_blank style='color:#2F92EE;'>#大手术#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=18, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=43712, encryptionId=b73f43e1224, topicName=大手术)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ecc933126179, createdName=Smile2691, createdTime=Wed Nov 07 02:51:00 CST 2018, time=2018-11-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=324085, encodeId=bd25324085bd, content=一起学习学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=45, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/vi_32/TDiaAWyicHgedzX3wKo3qcxudVJib7AfibfvNeufHRF2jG3Bw8MmZyWjIhtBV1mpJI7Sy9n7RcBKK5t3CuOKuOFxkg/0, createdBy=dd702206933, createdName=wzb521zf, createdTime=Thu Jun 14 09:52:26 CST 2018, time=2018-06-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=324066, encodeId=28243240663b, content=学习了.长知识, beContent=null, objectType=article, channel=null, level=null, likeNumber=42, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20220115/46bcf39c32de4aa6b45c5f9d66c8ee77/6cb4a20c55bb4b7691122f47747bfca2.jpg, createdBy=9dad1662329, createdName=1ddf0692m34(暂无匿称), createdTime=Thu Jun 14 09:36:20 CST 2018, time=2018-06-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=324057, encodeId=917e32405e75, content=学了, beContent=null, objectType=article, channel=null, level=null, likeNumber=35, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTKcmgibQ4oCrK7Z6f4CvMcs4k7QUGCkhopcGxvxaBfVciadECSIwaRVttllIOEKumpEaRrq5PoOUxow/0, createdBy=e3bb2081203, createdName=哈哈869, createdTime=Thu Jun 14 08:43:35 CST 2018, time=2018-06-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=324056, encodeId=7f8a3240563d, content=学了, beContent=null, objectType=article, channel=null, level=null, likeNumber=42, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTKcmgibQ4oCrK7Z6f4CvMcs4k7QUGCkhopcGxvxaBfVciadECSIwaRVttllIOEKumpEaRrq5PoOUxow/0, createdBy=e3bb2081203, createdName=哈哈869, createdTime=Thu Jun 14 08:43:32 CST 2018, time=2018-06-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=324048, encodeId=1e793240480a, content=谢谢分享.学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=35, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo6Nx0VGA4QMDzOP8oAgnV4h51EjSfehJ9QxyiaSmw8PB56BhY8KXFSxHCibXrzcy4abrzSibXQPxJ9kzrLcJyhhB8a/0, createdBy=1d3b1672603, createdName=明月清辉, createdTime=Thu Jun 14 08:16:50 CST 2018, time=2018-06-14, status=1, ipAttribution=)]
    2018-06-14 明月清辉

    谢谢分享.学习了

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