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[路透社健康信息]:腹部手术期间限制性输液没有益处,且可能增加肾脏损伤风险
2018年05月26日 研究点评, 进展交流 暂无评论

Restricting Fluids During Abdominal Surgery Shows No Benefit, Possible Renal Risk

By Gene Emery

May 11, 2018

(Reuters Health) - In a discovery that goes against emerging surgical wisdom, a new study suggests that restricting intravenous fluids before major abdominal surgery not only fails to make the operation safer for higher-risk patients, it may cause short-term kidney injury.

一项新的研究结果提示,腹部大手术前限制静脉液体不仅无法保证高危患者的手术安全,还可能导致短期肾损伤。

The rate of acute renal injury was 8.6% among 1,490 volunteers with a restricted fluid regimen versus 5.0% in a group of 1,493 getting a liberal IV-fluid regimen (P<0.001).

限制输液组1490名患者中急性肾损伤的发生率为8.6%,自由输液组1493名患者中发生率为5.0% (P<0.001)。

The risk of septic complications or death within 30 days was similar in the two groups - as high as 21.8% in the restrictive fluid group - but the research team, reporting online May 10 in The New England Journal of Medicine, also saw modestly significant increases in the rates of surgical-site infection and the need for renal-replacement therapy when fluids were restricted to replacement only.

两组患者30天内感染性并发症或死亡的风险没有差异—限制输液组高达21.8%—但研究团队同时发现,当静脉输液仅限于补充丢失,手术部位感染率及需要肾脏替代治疗的患者比例呈轻度升高。这一研究结果于5月10日在线发表于新英格兰医学杂志。

"Our results are really quite surprising," chief author Paul Myles of Monash University in Australia told Reuters Health in a telephone interview. "We could not identify any benefits of restrictive fluids, which is the technique experts have been using recently. In fact, we found more harm."

“我们的结果非常令人奇怪,”研究的第一作者,澳大利亚Monash大学的Paul Myles在电话访谈中对路透社健康频道谈到。“我们未能发现限制输液的任何好处,然而这确是专家们近期常规使用的输液策略。事实上,我们发现[限制输液]有更多危害。”

But the team stressed in their paper that the findings "should not be used to support excessive administration of intravenous fluid. Rather, they show that a regimen that includes a modestly liberal administration of fluid is safer than a restrictive regimen."

但是,研究团队在论文中强调,这一发现“不能作为支持过多进行静脉输液的证据。相反,研究表明,一定程度的自由输液策略较限制输液更加安全。”

"There's been no debate that if you give too much or too little fluid, it causes harm," Dr. Myles said by phone. "But we didn't know where the sweet spot was, and that was the purpose of this study. We now know where the sweet spot is, and that really is going to change practice around the world."

“如果输液过多或过少,都会造成损伤,这一点毋庸置疑,”Myles医生在电话中谈到。“但是,我们并不知道拐点在哪里,这正是本研究的目的。我们现在知道拐点在何处,这将会改变全世界的临床行为。”

"The result may surprise many surgeons and anesthesiologists, who no doubt expected that the outcome would favor the restrictive fluid group," said Birgitte Brandstrup of Holbaek Hospital, Denmark, in a Journal editorial.

“研究结果可能使很多外科医生及麻醉科医生感到奇怪,这些人无疑都预期研究结果倾向于限制输液组,”来自丹麦Holbaek医院的Birgitte Brandstrup在述评中写到。

"The findings we have in this setting are very generalizable to all types of patients having major abdominal surgery and, I would argue, any type of major surgery," Dr. Myles said.

“我们的研究结果可以推广到接受腹部大手术的所有类型患者,甚至适用于所有类型的大手术,”Myles医生谈到。

The results were also reported Thursday at the Australian and New Zealand College of Anaesthetists' annual scientific meeting in Sydney, Australia.

研究结果于周四在澳大利亚悉尼召开的澳大利亚新西兰麻醉师学院年度会议上宣读。

Conventional fluid administration can add 3 to 6 kilograms to a patient's weight, and some small studies have suggested that restricting the amounts might reduce complications.

传统的输液治疗可使患者体重增加3-6千克,一些小样本研究提示,限制输液量能够减少并发症。

In the new pragmatic international study, known as RELIEF, patients in the restricted fluid group were only given enough fluid to replace what they were losing.

在这项称为RELIEF的新的实效性国际研究中,限制输液组的患者仅仅接受补充体液丢失的液体。

Their median intake was 3.7 liters during and up to 24 hours after surgery versus 6.1 liters in the liberal intake group.

限制输液组患者在手术期间直至手术后24小时中位液体入量为3.7 L,自由输液组为6.1 L。

All of the study participants were at higher risk for complications based on several criteria, such as being at least 70 years old, being morbidly obese or having heart disease, renal impairment or diabetes.

根据判断标准,所有研究对象均为并发症高危患者,例如至少70岁,病态肥胖,心脏病,肾功能不全或糖尿病。

The odds of disability-free survival at one year showed no benefit for the restrictive-fluid regimen, with rates of 81.9% and 82.3% respectively (P=0.61).

限制输液组一年后无残疾生存率并无获益,两组患者分别为81.9% 和 82.3% (P=0.61)。

Surgical-site infection rates were 16.5% with restricted intake and 13.6% without. Renal-replacement therapy was provided to 0.9% of volunteers on restricted fluids, three times higher than the rate among patients receiving unrestricted fluids (P=0.48).

限制输液组患者手术部位感染率16.5%,自由输液组为13.6%。限制输液组肾脏替代治疗比例为0.9%,较自由输液组患者高3倍(P=0.48)。

The study, which was not blinded and included a range of abdominal surgeries, was done at 47 centers in seven countries.

研究并未设盲,纳入多种腹部手术患者,在7个国家的47个中心进行。

Dr. Brandstrup said there may be several reasons why earlier research suggested a benefit to restricted fluids while the RELIEF study does not. For example, the older tests were done when surgery was more invasive, producing more stress that leads to fluid retention.

Brandstrup医生谈到,早期研究提示限制输液有益,而RELIEF研究却未能证实,其原因可能有多种。例如,进行既往研究时手术创伤更大,因而造成更多应激引起液体潴留。

SOURCE: https://bit.ly/2ryeT1j

N Engl J Med 2018.

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