重症成人平衡晶体液液与盐水的比较
# 重症成人平衡晶体液液与盐水的比较
Matthew W. Semler, M.D., Wesley H. Self, M.D., M.P.H., Jonathan P. Wanderer, M.D., Jesse M. Ehrenfeld, M.D., M.P.H., Li Wang, M.S., Daniel W. Byrne, M.S., Joanna L. Stollings, Pharm.D., Avinash B. Kumar, M.D., Christopher G. Hughes, M.D., Antonio Hernandez, M.D., Oscar D. Guillamondegui, M.D., M.P.H., Addison K. May, M.D., et al., for the SMART Investigators and the Pragmatic Critical Care Research Group*
N Engl J Med 2018; 378:829-839 DOI: 10.1056/NEJMoa1711584
# 摘要
背景 平衡晶体液和生理盐水都可用于危重成人静脉输液，但尚不清楚临床效果哪种更好。
方法： 在一家学术研究中心的五个 ICU 病房进行的一项实用的、丛集随机、多重交叉试验中，根据随机住院的病房不同，将 15,802 名成人随机分为输注生理盐水 (0.9% 氯化钠) 或平衡晶体液 (乳酸林格液或勃脉力) 两组。主要结果是 30 天内的主要肾脏不良事件（全因死亡、新开始的肾脏替代治疗或持续肾功能障碍 (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 平衡晶体液组 7942 例患者中，有 1139 例 (14.3%) 发生了主要肾脏不良事件，而生理盐水组 7860 例患者中有 1211 例 (15.4%) 发生了主要肾脏不良事件 (边际优势比 0.91；95% 可信区间 [CI] 0.84~0.99；条件优势比 0.90；95% CI 0.82~0.99；P=0.04)。30 天住院死亡率平衡晶体液组为 10.3%，生理盐水组为 11.1%(P=0.06)。新开始的肾脏替代治疗的发生率分别为 2.5% 和 2.9% (P=0.08)，持续肾功能不全的发生率分别为 6.4% 和 6.6% (P=0.60)。
结论 在危重成人中，对于由全因死亡、新开始的肾脏替代治疗或持续肾功能障碍构成的复合结果，静脉输注平衡晶体液比生理盐水的发生率更低。
Balanced Crystalloids versus Saline in Critically Ill Adults
# Abstract
BACKGROUND
Both balanced crystalloids and saline are used for intravenous fluid administration in critically ill adults, but it is not known which results in better clinical outcomes.
METHODS
In a pragmatic, cluster-randomized, multiple-crossover trial conducted in five intensive care units at an academic center, we assigned 15,802 adults to receive saline (0.9% sodium chloride) or balanced crystalloids (lactated Ringer’s solution or Plasma-Lyte A) according to the randomization of the unit to which they were admitted. The primary outcome was a major adverse kidney event 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
Among the 7942 patients in the balanced-crystalloids group, 1139 (14.3%) had a major adverse kidney event, as compared with 1211 of 7860 patients (15.4%) in the saline group (marginal odds ratio, 0.91; 95% confidence interval [CI], 0.84 to 0.99; conditional odds ratio, 0.90; 95% CI, 0.82 to 0.99; P=0.04). In-hospital mortality at 30 days was 10.3% in the balanced-crystalloids group and 11.1% in the saline group (P=0.06). The incidence of new renal-replacement therapy was 2.5% and 2.9%, respectively (P=0.08), and the incidence of persistent renal dysfunction was 6.4% and 6.6%, respectively (P=0.60).
CONCLUSIONS
Among critically ill adults, the use of balanced crystalloids for intravenous fluid administration resulted in a lower rate of the composite outcome of death from any cause, new renal-replacement therapy, or persistent renal dysfunction than the use of saline.
参考：NEJM 医学前沿的译文