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腹部大手术后限制性和开放性液体治疗的比较
Restrictive versus Liberal Fluid Therapy for Major Abdominal Surgery


Paul S. Myles ... 其他 • 2018.06.14

摘要


背景

促进大手术后患者早期恢复的指南建议对腹部手术采用限制性静脉补液策略。然而,支持性证据有限,并且存在器官灌注受损的担心。

 

方法

在一项实用性、国际性试验中,我们将3,000例接受腹部大手术时并发症风险高的患者随机分组,在手术期间和术后24小时内分别接受限制性或开放性静脉补液治疗。主要结局为1年时的无失能生存率。关键次要结局包括30日时的急性肾损伤、90日时的肾脏替代治疗以及感染性并发症、手术部位感染或死亡构成的复合结局。

 

结果

在手术期间和术后24小时内,限制性补液组1,490例患者和开放性补液组1,493例患者的中位静脉补液量分别为3.7 L(四分位距,2.9~4.9 L)和6.1 L(四分位距,5.0~7.4 L)(P<0.001)。在限制性补液组和开放性补液组中,1年时的无失能生存率分别为81.9%和82.3%(死亡或失能的风险比,1.05;95%置信区间,0.88~1.24;P=0.61)。在限制性补液组和开放性补液组中,急性肾损伤的发生率分别为8.6%和5.0%(P<0.001)。在限制性补液组和开放性补液组中,感染性并发症或死亡的发生率分别为21.8%和19.8%(P=0.19);在限制性补液组中,手术部位感染(16.5% vs. 13.6%,P=0.02)和肾脏替代疗法(0.9% vs. 0.3%,P=0.048)的发生率较高,但在多重检验校正后,组间差异不显著。

 

结论

在腹部大手术期间并发症风险高的患者中,与开放性补液相比,限制性补液并未与较高的无失能生存率相关,但与较高的急性肾损伤发生率相关(由澳大利亚国家健康与医学研究委员会[Australian National Health and Medical Research Council]等资助;RELIEF在ClinicalTrials.gov注册号为NCT01424150)。 





作者信息

Paul S. Myles, M.P.H., D.Sc., Rinaldo Bellomo, M.D., Tomas Corcoran, M.D., Andrew Forbes, Ph.D., Philip Peyton, M.D., Ph.D., David Story, M.D., Chris Christophi, M.B., B.S., Kate Leslie, M.D., Shay McGuinness, M.B., Ch.B., Rachael Parke, M.P.H., Jonathan Serpell, M.D., Matthew T.V. Chan, M.B., B.S., et al., for the Australian and New Zealand College of Anaesthetists Clinical Trials Network and the Australian and New Zealand Intensive Care Society Clinical Trials Group*
From Alfred Hospital (P.S.M., J.S., S.W.), Monash University (P.S.M., R.B., T.C., A.F., K.L., J.S., S.W.), and the University of Melbourne (R.B., P.P., D.S., C.C., K.L.), Melbourne, VIC, Austin Hospital, Heidelberg, VIC (R.B., P.P., D.S., C.C.), Royal Perth Hospital and the University of Western Australia, Perth (T.C.), Royal Melbourne Hospital, Parkville, VIC (K.L.), and Royal Adelaide Hospital and Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA (T.P.) — all in Australia; Auckland City Hospital, Auckland, and the Medical Research Institute of New Zealand, Wellington — both in New Zealand (S. McGuinness, R.P.); the Chinese University of Hong Kong, Hong Kong (M.T.V.C.); University Health Network, Toronto (S. McCluskey); and Derriford Hospital, Plymouth, United Kingdom (G.M.). Address reprint requests to Dr. Myles at the Department of Anaesthesia and Perioperative Medicine, Alfred Hospital, Commercial Rd., Melbourne, VIC 3004, Australia, or at p.myles@alfred.org.au. *A list of participating centers and investigators in the RELIEF trial is provided in the Supplementary Appendix, available at NEJM.org.

 

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