不同液体复苏对低血容量性休克患者肾及凝血功能的影响
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摘要
目的:探讨不同液体复苏对低血容量性休克患者肾及凝血功能的影响。方法:将295例术后8 h内出现低血容量性休克的患者随机分为3组:平衡液组(醋酸林格液)、0.9%氯化钠溶液组、6%羟乙基淀粉氯化钠(HES) 130/0.4组。结果:羟乙基淀粉组AKI发病率(12.5%)相较于生理盐水(7.3%)、醋酸林格组(6.3%)有升高趋势,但差异无统计学意义(P>0.05);其中泌尿外科患者AKI发病率(11.1%)相较于肝胆外科(5.6%)、胃肠外科(6.5%)及其他科室(7.7%)升高(P<0.05);泌尿外科患者中,羟乙基淀粉组AKI发生率(17.5%)相较于生理盐水组(8.9%)、醋酸林格组(8%)升高(P<0.05);羟乙基淀粉组凝血功能示:入室6 h时APTT与0 h(入室时)、24 h相较均有显著延长,有统计学差异,(P<0.05);入室6 h及24 h时DD二聚体均较0 h(入室时)显著升高,有统计学差异,(P<0.05)。生理盐水组凝血功能示:入室24 h时PT与0 h(入室时)相较显著延长,有统计学差异(P<0.05);入室6 h羟乙基淀粉组PT与APTT均较醋酸林格组显著延长,有统计学差异,(P<0.05);入室6 h生理盐水组PT较醋酸林格组显著延长,有统计学差异,(P<0.05);入室6 h羟乙基淀粉组DD二聚体较醋酸林格组显著升高,有统计学差异,(P<0.05)。羟乙基淀粉组、醋酸林格、生理盐水组术后活动性出血率无统计学差异。结论:1.外科术后低血容量性休克患者使用羟乙基淀粉氯化钠溶液及生理盐水扩容补液,并未增加患者肾损害的风险; 2.外科术后低血容量性休克患者使用羟乙基淀粉氯化钠溶液及生理盐水扩容补液对凝血功能有一定影响,但未导致术后出血风险增加; 3.泌尿外科术后低血容量性休克患者急性肾损伤(AKI)风险较其他外科术后低血容量性休克患者高,且使用羟乙基淀粉溶液增加泌尿外科手术后低血容量性休克患者发生AKI的风险。
Objective: To investigate the impacts of fluid resuscitation regimens on renal and coagulation function in patients with hypovolemic shock. Methods: Included in this study were 295 patients with hypovolemic shock which occurred within 8 h after surgery,randomized into three groups: balanced solution group( Ringer's acetate solution,RAS),0.9% sodium chloride( NS) group,and 6% hydroxyethyl starch( HES) sodium chloride130/0.4 group. Results: The incidence of AKI in the HES group( 12.5%) appeared to be higher than those in the NS group( 7.3%) and RAS group( 6.3%),but the difference was not statistically significant( P>0.05). The incidence of AKI in patients after urological surgery( 11.1%) was higher than those after hepatobiliary surgery( 5.6%),gastrointestinal surgery( 6. 5%) and other surgeries( 7. 7%)( P < 0. 05). Among patients after urological surgery,the incidence of AKI with HES( 17. 5%) was higher than those with NS( 8. 9%) and RAS( 8%)( P < 0. 05). Coagulation function test showed that: in the HES group,the 6 h APTT was significantly prolonged compared with 0 h( at the time of ICU admission) and 24 h APTT with statistical differences( P <0. 05),and the 6 h and 24 h D-dimer levels were significantly higher than the 0 h D-dimer level with statistical differences( P<0.05); in the NS group,the 24 h PT was significantly prolonged compared with the 0 h PT with statistical difference( P < 0. 05). The 6 h PT and 6 h APTT in the HES group were significantly prolonged compared with those in the RAS group with statistical differences( P< 0.05). The 6 h PT in the NS group was significantly prolonged compared with that in the RAS group with statistical difference( P < 0. 05). The 6 h D-dimer level in the HES group was significantly higher compared with the RAS group with statistical difference( P<0.05). There was no significant difference in the incidence of active bleeding among the HES,NS and RAS groups. Conclusion: 1. Fluid replacement in hypovolemic shock after surgery using HES or NS does not increase the risk of renal impairment. 2. Fluid replacement in hypovolemic shock after surgery using HES or NS may somehow interfere with the coagulation function but does not lead to increased risk of postoperative bleeding.3.The risk of AKI in patients with hypovolemic shock after urological surgery is higher compared with those after other surgeries; moreover,use of HES in patients with hypovolemic shock after urological surgery may be associated with higher risk of AKI.
Objective: To investigate the impacts of fluid resuscitation regimens on renal and coagulation function in patients with hypovolemic shock. Methods: Included in this study were 295 patients with hypovolemic shock which occurred within 8 h after surgery,randomized into three groups: balanced solution group( Ringer's acetate solution,RAS),0.9% sodium chloride( NS) group,and 6% hydroxyethyl starch( HES) sodium chloride130/0.4 group. Results: The incidence of AKI in the HES group( 12.5%) appeared to be higher than those in the NS group( 7.3%) and RAS group( 6.3%),but the difference was not statistically significant( P>0.05). The incidence of AKI in patients after urological surgery( 11.1%) was higher than those after hepatobiliary surgery( 5.6%),gastrointestinal surgery( 6. 5%) and other surgeries( 7. 7%)( P < 0. 05). Among patients after urological surgery,the incidence of AKI with HES( 17. 5%) was higher than those with NS( 8. 9%) and RAS( 8%)( P < 0. 05). Coagulation function test showed that: in the HES group,the 6 h APTT was significantly prolonged compared with 0 h( at the time of ICU admission) and 24 h APTT with statistical differences( P <0. 05),and the 6 h and 24 h D-dimer levels were significantly higher than the 0 h D-dimer level with statistical differences( P<0.05); in the NS group,the 24 h PT was significantly prolonged compared with the 0 h PT with statistical difference( P < 0. 05). The 6 h PT and 6 h APTT in the HES group were significantly prolonged compared with those in the RAS group with statistical differences( P< 0.05). The 6 h PT in the NS group was significantly prolonged compared with that in the RAS group with statistical difference( P < 0. 05). The 6 h D-dimer level in the HES group was significantly higher compared with the RAS group with statistical difference( P<0.05). There was no significant difference in the incidence of active bleeding among the HES,NS and RAS groups. Conclusion: 1. Fluid replacement in hypovolemic shock after surgery using HES or NS does not increase the risk of renal impairment. 2. Fluid replacement in hypovolemic shock after surgery using HES or NS may somehow interfere with the coagulation function but does not lead to increased risk of postoperative bleeding.3.The risk of AKI in patients with hypovolemic shock after urological surgery is higher compared with those after other surgeries; moreover,use of HES in patients with hypovolemic shock after urological surgery may be associated with higher risk of AKI.
引文
[1]Yunos NM,Bellomo R,Story D,et al. Bench-to-bedside review:chloride in critical illness[J]. Crit Care,2010,14(4):226.
[2]Lameire NH,Bagga A,Cruz D,et al. Acute kidney injury:an increasing global concern[J]. Lancet,2013,382(9887):170-179.
[3] Raghunathan K,Nailer P,Konoske R. What is the ideal crystalloid[J]. Curr Opin Crit Care,2015,21(4):309-314.
[4] McCluskey SA,Karkouti K,Wijeysundera D,et al. Hyperchloremia after noncardiac surgery is independently associated with increased morbidity and mortality:a propensitymatched cohort study[J]. Anesth Analg,2013,117(2):412-421.
[5]Meng ZH,Wolberg AS,Monroe DM 3rd,et al. The effect of temperature and p H on the activity of factor VIIa:implications for the efficacy of high-dose factor VIIa in hypothermic and acidotic patients[J]. J Trauma,2003,55(5):886–891.
[6] Engstrom M,Schott U,Romner B,et al. Acidosis impairs the coagulation:a thromboelastographic study[J]. J Trauma,2006,61(3):624-628.
[7]Myburgh JA,Finfer S,Bellomo R,et al. Hydroxyethyl starch or saline for fluid resuscitation in intensive care[J]. N Engl J Med,2012,367(20):1901-1911.
[8] Perner A,Haase N,Guttormsen AB,et al. Hydroxyethyl starch 130/0. 42 versus Ringer’s acetate in severe sepsis[J]. N Engl J Med,2012,367(2):124-134.
[9]Dellinger RP,Levy MM,Rhodes A,et al. Surviving sepsis campaign:international guidelines for management of severe sepsis and septic shock:2012[J]. Crit Care Med,2013,41(2):580-637.
[10]Haase N,Müller R,Perner A. Debate on HES safety is important,but must be based on facts[J]. Scand J Trauma Resusc Emerg Med,2013,21:66.
[11]Jeffrey TC,David Banks,Mauney MC,et al. Intraoperative Hetastarch Infusion Impairs Hemostasis After Cardiac Operations[J]. The Annals of Thoracic Surgery,1997,63(1):78-82
[12]Frank van Haren,Zacharowski K. What's new in volume therapy in the intensive care unit[J]. Best Pract Res Clin Anaesthesiol,2014,28(3):275-283.
[13] Schick MA,Isbary TJ,Schlegel N,et al. The impact of crystalloid and colloid infusion on the kidney in rodent sepsis[J]. Intensive Care Med,2010,36:541-548.
[14]Huter L,Simon TP,Weinmann L,et al. Hydroxyethylstarch impairs renal function and induces interstitial proliferation,macrophage infiltration and tubular damage in an isolated renal perfusion model[J]. Crit Care,2009,13:R23.
[15] Myburgh JA,Finfer S,Bellomo R,et al. Hydroxyethyl starch or saline for fluid resuscitation in intensive care[J]. N Engl J Med,2012,367(20):1901-1911.
[16] Perner A,Haase N,Guttormsen AB,et al. Hydroxyethyl starch 130/0. 42 versus Ringer’s acetate in severe sepsis[J]. N Engl J Med,2012,367(2):124-134.
[17]Brunkhorst FM,Engel C,Bloos F,et al. Intensive insulin therapy and pentastarch resuscitation in severe sepsis[J].N Engl J Med,2008,358:125-139.
[18]Raiman M,Mitchell CG,Biccard BM,et al. Comparison of hydroxyethyl starch colloids with crystalloids for surgical patients:A systematic review and meta-analysis[J]. Eur J Anaesthesiol,2016,33:42-48.
[19]He B,Xu B,Xu X,et al. Hydroxyethyl starch versus other fluids for non-septic patients in the intensive care unit:a meta-analysis of randomized controlled trials[J]. Crit Care,2015,19:92.
[20]Kunze E,Stetter C,Willner N,et al.Effects of Fluid Treatment With Hydroxyethyl Starch on Renal Function in Patients With Aneurysmal Subarachnoid Hemorrhage[J]. J Neurosurg Anesthesiol,2016,28(3):187-194
[21] Brandstrup B,Tonnesen H,Beier-Holgersen R,et al.Effects of intravenous fluid restriction on postoperative complications:comparison of two perioperative fluid regimens:a randomized assessor-blinded multicenter trial[J].Ann Surg,2003,238:641-648.
[22] Yunos N M,Bellomo R,Hegary C,et al. Association between a chloride-liberal vs chloride-restrictive intravenous fluid admin-istration strategy and kidney injury in critically ill adults[J]. JAMA,2012,308(15):1566-1572.
[23]Suetrong B,Pisitsak C. Hyperchloremia and moderate increase in serum chloride are associated with acute kidney injury in severe sepsis and septic shock patients[J]. Crit Care,2016,20(1):315.
[24]Hasman H,Cinar O,Uzun A,et al. A randomized clinical trial comparing the effect of rapidly infused crystalloids on acid-base status in dehydrated patients in the emergency department[J]. Int J Med Sci,2012,9:59-64.
[25]Mahajan V,Sajan SS,Sharma A,et al. Ringers lactate vs Normal saline for children with acute diarrhea and severe dehydration-a double blind randomized controlled trial[J]. Indian Pediatr,2012,49:963-968.
[26]Moritz ML,Ayus JC. Maintenance Intravenous Fluids in Acutely Ill Patients[J]. N Engl J Med,2015,373:1350-1360.
[27]Young P,Bailey M,Beasley R,et al. Effect of a buffered crys-talloid solution vs saline on acute kidney injury among patients in the intensive care unit:the SPLIT randomized clinical trial[J]. JAMA,2015,314:1701-1710.
[28]El Gkotmi N,Kosmeri C,Filippatos TD,et al. Use of intravenous fluids/solutions:a narrative review[J]. Curr Med Res Opin,2017,33(3):459-471.
[29]Jonge E,Levi M. Effects of different plasma substitutes on blood coagulation:a comparative review[J]. Crit Care Med,2001,29,1261-1267.
[30]Jonge E,Levi M,Buller HR,et al. Decreased circulating levels of von Willebrand factor after intravenous administration of a rapidly degradable hydroxyethyl starch(HES200/0. 5/6)in healthy human subjects[J]. Intensive Care Med,2001,27:1825-1829.
[31] Innerhofer P,Fries D,Margreiter J,et al. The effects of perioperatively administered colloids and crystalloids on primary platelet-mediated hemostasis and clot formation[J]. Anesth Analg,2002,95:858-865.
[32]Treib J,Haass A,Pindur G,et al. All medium starches are not the same:influence of the degree of hydroxyethyl substitution of hydroxyethyl starch on plasma volume,hemorrheologic conditions,and coagulation[J]. Transfusion,1996,36:450-455.
[33]Vance G. Nielsen Hydroxyethyl starch enhances fibrinolysis in human plasma by diminishing a2-antiplasmin–plasmin interactions[J]. Blood Coagul Fibrinolysis,2007,18(7):647-656.
[34]Navickis RJ,Haynes GR,Wilkes MM. Effect of hydroxyethyl starch on bleeding after cardiopulmonary bypass:a meta-analysis of randomized trials[J]. J Thorac Cardiovasc Surg,2012,144:223-230.
[35] Hung MH,Zou C,Lin FS,et al. New 6%hydroxyethyl starch 130/0.4 does not increase blood loss during major abdominal surgery-a randomized,controlled trial[J]. J Formos Med Assoc,2014,113(7):429-435.
[36]Waters JH,Gottlieb A,Schoenwald P,et al. Normal saline versus lactated Ringer's solution for intraoperative fluid management in patients undergoing abdominal aortic aneurysm repair:an outcome study[J]. Anesth Analg,2001,93:817-822.
[37]Todd SR,Malinoski D,Muller PJ,et al. Lactated Ringer’s is Superior to Normal Saline in the Resuscitation of Uncontrolled Hemorrhagic Shock[J]. J Trauma,2007,62:636-639.
[2]Lameire NH,Bagga A,Cruz D,et al. Acute kidney injury:an increasing global concern[J]. Lancet,2013,382(9887):170-179.
[3] Raghunathan K,Nailer P,Konoske R. What is the ideal crystalloid[J]. Curr Opin Crit Care,2015,21(4):309-314.
[4] McCluskey SA,Karkouti K,Wijeysundera D,et al. Hyperchloremia after noncardiac surgery is independently associated with increased morbidity and mortality:a propensitymatched cohort study[J]. Anesth Analg,2013,117(2):412-421.
[5]Meng ZH,Wolberg AS,Monroe DM 3rd,et al. The effect of temperature and p H on the activity of factor VIIa:implications for the efficacy of high-dose factor VIIa in hypothermic and acidotic patients[J]. J Trauma,2003,55(5):886–891.
[6] Engstrom M,Schott U,Romner B,et al. Acidosis impairs the coagulation:a thromboelastographic study[J]. J Trauma,2006,61(3):624-628.
[7]Myburgh JA,Finfer S,Bellomo R,et al. Hydroxyethyl starch or saline for fluid resuscitation in intensive care[J]. N Engl J Med,2012,367(20):1901-1911.
[8] Perner A,Haase N,Guttormsen AB,et al. Hydroxyethyl starch 130/0. 42 versus Ringer’s acetate in severe sepsis[J]. N Engl J Med,2012,367(2):124-134.
[9]Dellinger RP,Levy MM,Rhodes A,et al. Surviving sepsis campaign:international guidelines for management of severe sepsis and septic shock:2012[J]. Crit Care Med,2013,41(2):580-637.
[10]Haase N,Müller R,Perner A. Debate on HES safety is important,but must be based on facts[J]. Scand J Trauma Resusc Emerg Med,2013,21:66.
[11]Jeffrey TC,David Banks,Mauney MC,et al. Intraoperative Hetastarch Infusion Impairs Hemostasis After Cardiac Operations[J]. The Annals of Thoracic Surgery,1997,63(1):78-82
[12]Frank van Haren,Zacharowski K. What's new in volume therapy in the intensive care unit[J]. Best Pract Res Clin Anaesthesiol,2014,28(3):275-283.
[13] Schick MA,Isbary TJ,Schlegel N,et al. The impact of crystalloid and colloid infusion on the kidney in rodent sepsis[J]. Intensive Care Med,2010,36:541-548.
[14]Huter L,Simon TP,Weinmann L,et al. Hydroxyethylstarch impairs renal function and induces interstitial proliferation,macrophage infiltration and tubular damage in an isolated renal perfusion model[J]. Crit Care,2009,13:R23.
[15] Myburgh JA,Finfer S,Bellomo R,et al. Hydroxyethyl starch or saline for fluid resuscitation in intensive care[J]. N Engl J Med,2012,367(20):1901-1911.
[16] Perner A,Haase N,Guttormsen AB,et al. Hydroxyethyl starch 130/0. 42 versus Ringer’s acetate in severe sepsis[J]. N Engl J Med,2012,367(2):124-134.
[17]Brunkhorst FM,Engel C,Bloos F,et al. Intensive insulin therapy and pentastarch resuscitation in severe sepsis[J].N Engl J Med,2008,358:125-139.
[18]Raiman M,Mitchell CG,Biccard BM,et al. Comparison of hydroxyethyl starch colloids with crystalloids for surgical patients:A systematic review and meta-analysis[J]. Eur J Anaesthesiol,2016,33:42-48.
[19]He B,Xu B,Xu X,et al. Hydroxyethyl starch versus other fluids for non-septic patients in the intensive care unit:a meta-analysis of randomized controlled trials[J]. Crit Care,2015,19:92.
[20]Kunze E,Stetter C,Willner N,et al.Effects of Fluid Treatment With Hydroxyethyl Starch on Renal Function in Patients With Aneurysmal Subarachnoid Hemorrhage[J]. J Neurosurg Anesthesiol,2016,28(3):187-194
[21] Brandstrup B,Tonnesen H,Beier-Holgersen R,et al.Effects of intravenous fluid restriction on postoperative complications:comparison of two perioperative fluid regimens:a randomized assessor-blinded multicenter trial[J].Ann Surg,2003,238:641-648.
[22] Yunos N M,Bellomo R,Hegary C,et al. Association between a chloride-liberal vs chloride-restrictive intravenous fluid admin-istration strategy and kidney injury in critically ill adults[J]. JAMA,2012,308(15):1566-1572.
[23]Suetrong B,Pisitsak C. Hyperchloremia and moderate increase in serum chloride are associated with acute kidney injury in severe sepsis and septic shock patients[J]. Crit Care,2016,20(1):315.
[24]Hasman H,Cinar O,Uzun A,et al. A randomized clinical trial comparing the effect of rapidly infused crystalloids on acid-base status in dehydrated patients in the emergency department[J]. Int J Med Sci,2012,9:59-64.
[25]Mahajan V,Sajan SS,Sharma A,et al. Ringers lactate vs Normal saline for children with acute diarrhea and severe dehydration-a double blind randomized controlled trial[J]. Indian Pediatr,2012,49:963-968.
[26]Moritz ML,Ayus JC. Maintenance Intravenous Fluids in Acutely Ill Patients[J]. N Engl J Med,2015,373:1350-1360.
[27]Young P,Bailey M,Beasley R,et al. Effect of a buffered crys-talloid solution vs saline on acute kidney injury among patients in the intensive care unit:the SPLIT randomized clinical trial[J]. JAMA,2015,314:1701-1710.
[28]El Gkotmi N,Kosmeri C,Filippatos TD,et al. Use of intravenous fluids/solutions:a narrative review[J]. Curr Med Res Opin,2017,33(3):459-471.
[29]Jonge E,Levi M. Effects of different plasma substitutes on blood coagulation:a comparative review[J]. Crit Care Med,2001,29,1261-1267.
[30]Jonge E,Levi M,Buller HR,et al. Decreased circulating levels of von Willebrand factor after intravenous administration of a rapidly degradable hydroxyethyl starch(HES200/0. 5/6)in healthy human subjects[J]. Intensive Care Med,2001,27:1825-1829.
[31] Innerhofer P,Fries D,Margreiter J,et al. The effects of perioperatively administered colloids and crystalloids on primary platelet-mediated hemostasis and clot formation[J]. Anesth Analg,2002,95:858-865.
[32]Treib J,Haass A,Pindur G,et al. All medium starches are not the same:influence of the degree of hydroxyethyl substitution of hydroxyethyl starch on plasma volume,hemorrheologic conditions,and coagulation[J]. Transfusion,1996,36:450-455.
[33]Vance G. Nielsen Hydroxyethyl starch enhances fibrinolysis in human plasma by diminishing a2-antiplasmin–plasmin interactions[J]. Blood Coagul Fibrinolysis,2007,18(7):647-656.
[34]Navickis RJ,Haynes GR,Wilkes MM. Effect of hydroxyethyl starch on bleeding after cardiopulmonary bypass:a meta-analysis of randomized trials[J]. J Thorac Cardiovasc Surg,2012,144:223-230.
[35] Hung MH,Zou C,Lin FS,et al. New 6%hydroxyethyl starch 130/0.4 does not increase blood loss during major abdominal surgery-a randomized,controlled trial[J]. J Formos Med Assoc,2014,113(7):429-435.
[36]Waters JH,Gottlieb A,Schoenwald P,et al. Normal saline versus lactated Ringer's solution for intraoperative fluid management in patients undergoing abdominal aortic aneurysm repair:an outcome study[J]. Anesth Analg,2001,93:817-822.
[37]Todd SR,Malinoski D,Muller PJ,et al. Lactated Ringer’s is Superior to Normal Saline in the Resuscitation of Uncontrolled Hemorrhagic Shock[J]. J Trauma,2007,62:636-639.