JAMA证据点评：住院儿童应用等张与低张静脉补液的比较

2015-12-30 峰译中国医学论坛报

临床问题在儿童维持静脉输液疗法中，与低张液相比，等张液是否与低钠血症的发生率较低相关? 要点与低张液相比，等张液与低钠血症的发生率较低相关，且没有不良转归增多的证据。与血浆相比，低张液所含的钠较少，常规处方用于维持儿童的水合状态。输注低张液可引起低钠血症，并且与包括脑水肿和死亡在内的不良转归相关1。这篇JAMA临床证据概要总结了一项近期的Cochrane综述，该综述比较了采用等张

临床问题在儿童维持静脉输液疗法中，与低张液相比，等张液是否与低钠血症的发生率较低相关?

要点与低张液相比，等张液与低钠血症的发生率较低相关，且没有不良转归增多的证据。

与血浆相比，低张液所含的钠较少，常规处方用于维持儿童的水合状态。输注低张液可引起低钠血症，并且与包括脑水肿和死亡在内的不良转归相关1。

这篇JAMA临床证据概要总结了一项近期的Cochrane综述，该综述比较了采用等张液与低张液维持儿童水合状态时，发生低钠血症的危险。

结果总结

与低张液相比，等张液与较低的低钠血症发生危险相关[等张液组的76例患者(17%)对低张液组的176例(34%)患者，危险比(RR)为0.48(95%CI为0.38～0.60，图。等张液与高钠血症发生危险增加不相关[等张液体组的16例患者(4%)对低张液体组的17例(3%)患者，RR为1.24(95%CI为0.65～2.38)]，与过度水合发生危险增加也不相关[等张液体组的9例患者(3%)对低张液体组的8例(3%)患者，RR为1.14(95%CI为0.46～-2.87)]。由于严重不良事件太少，因而无法对这些转归下结论。

讨论

在对Cochrane综述进行的初始检索完成以后，又有5项发表的研究3-7符合纳入标准(更新检索在2015年5月进行)。这些研究又纳入了1015例患者。这些研究的结果与科克伦综述的结果基本一致。有2项共包括173例患者的研究采用平均钠差异作为其主要转归，并且没有检出低钠血症发生率差异的效能4，7。其余的研究报告称低张液与低钠血症较低的发生率相关。

麦克纳伯等3进行的一项研究纳入了690例患者，其规模显著大于其他已发表的研究。结果与完整综述的主要结论一致。

局限性

首先，所纳入的研究并不适用于新生儿。荟萃分析只纳入了大部分患者年龄为3个月至18岁的研究。

其次，在所纳入的研究中，等张液之间存在异质性。某些研究使用的是0.9%氯化钠，其他研究使用的是含氯较少的平衡液。

研究结果与现有实践指南的比较

英国国家患者安全署8推荐将低张液用于维持水合状态，并且推荐等张液仅用于存在抗利尿激素分泌危险升高的儿童。这些指南与本文所报告的结果不一致。

需要进一步研究的领域

应该进行进一步的研究，以明确在新生儿中进行静脉维持液体治疗的理想钠浓度。进一步的研究应在特定的患者亚组(例如基线高钠的患者)中，对低张盐水与等张生理盐水进行比较。

原始出处：

McNab S.Isotonic vs Hypotonic Intravenous Fluids for Hospitalized Children. JAMA. 2015 Aug 18;314(7):720-1

McNab S1, Ware RS, Neville KA, Choong K, Coulthard MG, Duke T, Davidson A, Dorofaeff T.Isotonic versus hypotonic solutions for maintenance intravenous fluid administration in children.Cochrane Database Syst Rev. 2014 Dec 18;12:CD009457

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2016-07-13 fusion

#静脉#

29 0
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2016-02-16 mengli1984

值得儿科医师学习

82 0
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2016-01-27 1de3b290m83(暂无匿称)

不思考不出真知

84 0
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2016-01-01 lu2996

比较有用

174 0
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2015-12-31 忠诚向上

要注意

106 0
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2015-12-31 wzf990214

不错哦

104 0
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2015-12-31 wzf990214

赞一个

76 0
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2015-12-31 wzf990214

有意思

79 0

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