非危重成人平衡晶体与生理盐水的比较
# 非危重成人平衡晶体与生理盐水的比较
Wesley H. Self, M.D., M.P.H., Matthew W. Semler, M.D., Jonathan P. Wanderer, M.D., Li Wang, M.S., Daniel W. Byrne, M.S., Sean P. Collins, M.D., Corey M. Slovis, M.D., Christopher J. Lindsell, Ph.D., Jesse M. Ehrenfeld, M.D., M.P.H., Edward D. Siew, M.D., Andrew D. Shaw, M.B., Gordon R. Bernard, M.D., and Todd W. Rice, M.D., for the SALT-ED Investigators*
N Engl J Med 2018;378:819-28. DOI: 10.1056/NEJMoa1711586
# 摘要
背景 平衡晶体液和生理盐水的临床疗效比较尚不确定，特别是那些无需住 ICU 的非危重病人。
方法 我们进行了一项单中心、实用的、多重交叉试验，对急诊科静脉输注晶体液治疗并随后在除 ICU 以外的科室住院的成年人应用平衡晶体液 (乳酸林格或勃脉力) 和生理盐水进行比较。在为期 16 个月的试验中，急诊科给每个患者使用的晶体液种类以日历上的月为基础，平衡晶体液和生理盐水在整个急诊科按月交替使用。主要结果是非住院天数 (出院后第 28 天前的存活天数)。次要结果为 30 天内的主要肾脏不良事件（包括全因死亡、新开始的肾脏替代治疗或持续性肾功能障碍 (定义为肌酐水平上升至 ≥200% 的基线值)，所有调查都在出院时或 30 天内进行，以先发生者为准。
** 结果 ** 共有 13347 例患者入选，急诊应用晶体液的中位数为 1079 ml，88.3% 的患者只接受了规定的晶体液。平衡晶体液组和生理盐水组的非住院天数没有差异 (中位数，每组 25 天；平衡晶体液调整后的优势比为 0.98；95% 可信区间 [CI] 为 0.92 至 1.04；P=0.41)。平衡晶体液在 30 天内的主要肾脏不良事件发生率低于生理盐水 (4.7% 对 5.6%；调整后优势比为 0.82；95% 可信区间为 0.70 至 0.95；P=0.01)。
结论 在急诊科静脉输液治疗的非危重成人中，平衡晶体液治疗和生理盐水治疗的非住院天数没有差异。
Balanced Crystalloids versus Saline in Noncritically Ill Adults
# Abstract
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.
参考：NEJM 医学前沿的译文