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[Lancet Respir Med在线发表]:快速补液对接受气管插管的危重病患者心血管功能衰竭的影响
2019年11月27日 时讯速递, 进展交流 暂无评论

Effect of a fluid bolus on cardiovascular collapse among critically ill adults undergoing tracheal intubation (PrePARE): a randomised controlled trial

David R Janz, Jonathan D Casey, Matthew W Semler, et al

Lancet Respir Med. 2019 Oct 1. doi: 10.1016/S2213-2600(19)30246-2

Background 背景

Tracheal intubation is common in the care of critically ill adults and is frequently complicated by hypotension, cardiac arrest, or death. We aimed to evaluate administration of an intravenous fluid bolus to prevent cardiovascular collapse during intubation of critically ill adults.

气管插管是成年危重病患者经常接受的操作,其常见并发症包括低血压、心跳骤停或死亡。我们旨在评估气管插管期间静脉快速补液预防成年危重病患者心血管功能衰竭的作用。

Methods 方法

We did a pragmatic, multicentre, unblinded, randomised trial in nine sites (eight ICUs and one emergency department) around the USA. Critically ill adults (≥18 years) undergoing tracheal intubation were randomly assigned (1:1, block sizes of 2, 4, and 6, stratified by study site) to either an intravenous infusion of 500 mL of crystalloid solution or no fluid bolus. The primary outcome, assessed in the intention-to-treat population, was cardiovascular collapse, defined as a new systolic blood pressure <65 mm Hg; new or increased vasopressor receipt between induction and 2 min after tracheal intubation; or cardiac arrest or death within 1 h of tracheal intubation. Adverse events were assessed in the as-treated population. This trial, which is now complete, is registered with  ClinicalTrials.gov , number  NCT03026777 .

我们在美国9个中心(8个ICU及1个急诊科)进行了一项实效性、多中心、非盲、随机对照试验。接收气管插管的成年 (≥18 岁) 危重病患者接收随机分组(按照1:1的比例,区组大小为2, 4 和 6,根据中心分层),分别接受静脉输注500 mL晶体液或无快速补液。针对意向治疗人群评估主要预后指标即心血管功能衰竭,定义为新发收缩压<65 mm Hg;插管诱导及气管插管后2分钟内需要升压药物或原有升压药物剂量增加;气管插管后1小时内心跳骤停或死亡。针对接受治疗人群评估不良事件。这项试验在ClinicalTrials.gov 注册,注册号 NCT03026777

Findings 结果

Patients were enrolled from Feb 6, 2017, to Jan 9, 2018, when the data and safety monitoring board stopped the trial on the basis of futility. By trial termination, 337 (63%) of 537 screened adults had been randomly assigned. Cardiovascular collapse occurred in 33 (20%) of 168 patients in the fluid bolus group compared with 31 (18%) of 169 patients in the no fluid bolus group (absolute difference 1·3% [95% CI −7·1% to 9·7%]; p=0·76). The individual components of the cardiovascular collapse composite outcome did not differ between groups (new systolic blood pressure <65 mm Hg 11 [7%] in the bolus group  vs ten [6%] in the no-bolus group, new or increased vasopressor 32 [19%]  vs 31 [18%], cardiac arrest within 1 h seven [4%]  vs two [1%], death within 1 h of intubation two [1%]  vs one [1%]). In-hospital mortality was not significantly different in the fluid bolus group (48 [29%]) compared with no fluid bolus (59 [35%]).

2017年2月6日至2018年1月9日间入选患者,数据及安全监督委员会因治疗无效决定终止试验。至试验终止时,537名经过筛查的成年患者中337名(63%) 接收随机分组。快速补液组168名患者中33名 (20%) 及无快速补液组169名患者中31名 (18%) 发生心血管功能衰竭(绝对差异 1·3% [95% CI −7·1% to 9·7%]; p=0·76)。心血管功能衰竭中各个指标在两组间均没有差异 (新发收缩压<65 mm Hg 快速补液组11名 [7%] vs 无快速补液组10名 [6%],新使用升压药物或原有升压药物剂量增加 32 [19%]  vs 31 [18%],1小时内心跳骤停7 [4%]  vs 2 [1%],插管1小时内死亡2 [1%]  vs 1 [1%])。快速补液组 (48 [29%]) 与无快速补液组 (59 [35%]) 住院病死率无显著差异。

Interpretation 结论

Administration of an intravenous fluid bolus did not decrease the overall incidence of cardiovascular collapse during tracheal intubation of critically ill adults compared with no fluid bolus in this trial.

对于成年危重病患者而言,与无快速补液相比,气管插管期间静脉快速补液不能降低心血管功能衰竭的发生率。

Funding 资助

US National Institutes of Health.

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