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Timely utilization of transthoracic echocardiography can improve clinical outcomes after acute kidney injury in intensive care unit patients
Hu Yugang, Wang Hao, Yang Yuanting, Chen Yueying, Yu Fen, Zhou Qing
PDF(3775 KB)
Timely utilization of transthoracic echocardiography can improve clinical outcomes after acute kidney injury in intensive care unit patients
Objective To investigate the effect of usage of transthoracic echocardiography (TTE) on the prognosis of patients after acute kidney injury (AKI) in intensive care unit (ICU). Methods The clinical data of patients with AKI in the Medical Information Mart for Intensive Care (MIMIC-Ⅲ v1.4) database was collected retrospectively, and the patients were divided into TTE group (with TTE within 24 hours of AKI diagnosis) and No-TTE group (without TTE examination or first TTE examination was more than 24 hours after AKI diagnosis). Propensity score matching (PSM) was utilized to balance the baseline variables between the two groups and Cox regression analysis was used to evaluate the independent risk factors for 28-day all-cause mortality (the primary outcome). Moreover, after PSM, the effects of TTE usage on the second outcomes (including the volumes of intravenous fluid and urine output in the first, second and third 24-hour after the diagnosis of AKI; the total number of mechanical ventilation-free days, renal replacement therapy-free days and vasopressor-free days within 28 days after ICU admission; use of diuretics after the diagnosis of AKI; reduction in serum creatinine within 48 hours after the diagnosis of AKI; and the length of ICU stay and hospital stay) were also evaluated. Results Among 23 945 eligible AKI patients, 3 365 patients (14.1%) patients received TTE within 24 hours after the diagnosis of AKI and finally there were 3 361 patients in TTE group and No-TTE group included in this study after PSM based on the ratio of 1∶1. After PSM, all variables in the two groups were well balanced (standardized mean difference<0.1, respectively). Before and after PSM, patients in TTE group had lower 28-day all-cause mortality compared with patients in No-TTE group (10.76% vs 13.04%, χ2=13.535, P<0.001; 10.65% vs 18.80%, χ2=88.932, P<0.001), and Kaplan-Meier survival curves also revealed that patients in the TTE group had higher cumulative survival rate compared with patients in No-TTE group (Log-rank χ2=15.438, P<0.001; Log-rank χ2=75.360, P<0.001, respectively). Multivariate Cox regression analysis showed that TTE was an independent influencing factor for 28-day all-cause mortality before and after PSM (HR=0.80, 95%CI 0.73-0.89, P<0.001; HR=0.58, 95%CI 0.51-0.65, P<0.001). And all subgroup analyses showed the similar results. Compared with patients in the No-TTE group, patients in the TTE group had higher volume of intravenous fluid on the first day and the second day after the diagnosis of AKI (both P<0.01). Patients in the TTE group had higher volume of urine output on the first day and the third day after the diagnosis of AKI (both P<0.01). The patients in the TTE group had a significantly lower duration of vasopressor-free and mechanical ventilation-free (both P<0.01). The usage of diuretic was significantly higher in the TTE group compared with that in the No-TTE group (54.1% vs 44.2%, χ2=65.609, P<0.001). With respect to serum creatinine, the reduction in serum creatinine within 48 hours after the diagnosis of AKI was higher in the TTE group than that in the No-TTE group [36.6(23.0, 97.2) μmol/L vs 30.1(14.2, 61.9) μmol/L, Z=-9.549, P<0.001]. Moreover, TTE group had shorter ICU stay than that in the No-TTE group [5.03(3.40, 8.90) d vs 5.37(3.77, 10.00) d, Z=-6.589, P<0.001]. There were no significant difference between the two groups in other secondary outcomes (all P>0.05). Conclusions Timely TTE utilization after AKI incident is associated with better clinical outcomes for ICU patients.
Echocardiography / Acute kidney injury / Intensive care units / Prognosis / Propensity score matching {{custom_keyword}} /
表1 两组患者基线资料的比较 |
| 项目 | PSM前 | PSM后 | ||||||
|---|---|---|---|---|---|---|---|---|
| No-TTE组(n=20 580) | TTE组(n=3 365) | SMD | P值 | No-TTE组(n=3 361) | TTE组(n=3 361) | SMD | P值 | |
| 年龄(岁) | 66.8±15.8 | 68.7±15.0 | 0.133 | <0.001 | 69.1±15.8 | 68.8±15.0 | 0.018 | 0.885 |
| 男性[例(%)] | 11 756(57.1) | 1 753(52.1) | 0.102 | <0.001 | 1 748(52.0) | 1 749(52.0) | 0.001 | 0.981 |
| 体重(kg) | 84.4±24.3 | 85.2±25.5 | 0.025 | 0.080 | 85.0±26.2 | 85.0±25.3 | 0.001 | 0.499 |
| AKI诊断前治疗[例(%)] | ||||||||
| 机械通气 | 9 569(46.5) | 939(27.9) | 0.392 | <0.001 | 963(28.7) | 939(27.9) | 0.016 | 0.516 |
| 血管加压药 | 6 239(30.3) | 647(19.2) | 0.259 | <0.001 | 645(19.2) | 647(19.3) | 0.002 | 0.951 |
| 肾脏替代治疗 | 295(1.4) | 60(1.8) | 0.028 | 0.120 | 55(1.6) | 60(1.8) | 0.011 | 0.638 |
| 重症评分(分) | ||||||||
| 序贯器官衰竭评分 | 4.0(2.0，6.0) | 5.0(3.0，9.0) | 0.070 | <0.001 | 4.0(2.0，7.0) | 4.0(2.0，7.0) | 0.011 | 0.715 |
| 简化急性生理评分Ⅲ | 37.6±13.8 | 39.2±13.2 | 0.165 | <0.001 | 39.8±14.5 | 39.8±13.4 | 0.013 | 0.862 |
| 合并症[例(%)] | ||||||||
| 高血压 | 9 921(48.2) | 1 600(47.5) | 0.016 | 0.401 | 1 574(46.8) | 1 597(47.5) | 0.014 | 0.622 |
| 糖尿病 | 6 087(29.6) | 1 114(33.1) | 0.077 | 0.002 | 1 102(32.8) | 1 112(33.1) | 0.006 | 0.795 |
| 慢性肾脏病 | 2 376(11.5) | 509(15.1) | 0.105 | <0.001 | 532(15.8) | 509(15.1) | 0.019 | 0.438 |
| 冠状动脉疾病 | 6 776(32.9) | 1 287(38.2) | 0.111 | <0.001 | 1 289(38.4) | 1 283(38.2) | 0.004 | 0.880 |
| 充血性心力衰竭 | 6 454(31.4) | 1 517(45.1) | 0.288 | <0.001 | 1 520(45.2) | 1 514(45.0) | 0.004 | 0.883 |
| 恶性肿瘤 | 3 591(17.4) | 515(15.3) | 0.057 | 0.002 | 514(15.3) | 515(15.3) | 0.001 | 0.973 |
| 生命体征 | ||||||||
| 平均动脉压(mmHg) | 106.0±27.7 | 104.8±28.4 | 0.042 | 0.022 | 105.0±26.4 | 104.8±28.5 | 0.005 | 0.637 |
| 心率(次/min) | 71.6±14.5 | 70.9±15.9 | 0.036 | 0.013 | 71.0±15.1 | 71.1±16.0 | 0.007 | 0.876 |
| 呼吸频率(次/min) | 12.1±3.8 | 12.8±3.8 | 0.196 | <0.001 | 12.9±3.9 | 12.8±3.8 | 0.014 | 0.829 |
| 体温(℃) | 36.0±0.8 | 36.0±0.9 | 0.013 | 0.692 | 36.1±0.8 | 36.0±0.9 | 0.014 | 0.534 |
| 实验室检查结果 | ||||||||
| 白细胞(×109/L) | 10.4(7.6，14.0) | 10.3(7.5，14.2) | 0.017 | 0.930 | 10.5(7.7，14.4) | 10.3(7.6，14.2) | 0.014 | 0.664 |
| 血红蛋白(g/L) | 108.8±20.6 | 110.6±20.9 | 0.074 | <0.001 | 110.0±20.0 | 110.0±21.0 | 0.003 | 0.659 |
| 血小板计数(×109/L) | 211.0(147.0，286.0) | 222.0(158.0，295.0) | 0.184 | <0.001 | 220.0(157.0，295.0) | 221.0(157.0，295.0) | 0.025 | 0.558 |
| 总胆红素(mmol/L) | 1.0(0.5，1.6) | 0.8(0.4，1.6) | 0.041 | <0.001 | 0.8(0.4，1.6) | 0.8(0.4，1.6) | 0.014 | 0.325 |
| 白蛋白(g/L) | 31.2±5.8 | 31.3±5.8 | 0.013 | 0.511 | 31.1±5.8 | 31.0±5.8 | 0.014 | 0.849 |
| 血尿素氮(mmol/L) | 1.5±0.6 | 1.6±0.6 | 0.131 | <0.001 | 1.6±0.6 | 1.7±0.6 | 0.022 | 0.981 |
| 血肌酐(μmol/L) | 113.2±36.1 | 118.9±36.4 | 0.071 | <0.001 | 119.7±34.0 | 121.9±35.2 | 0.033 | 0.340 |
| 血乳酸(mmol/L) | 2.1(1.3，2.2) | 2.0(1.3，2.2) | 0.037 | 0.417 | 2.2(1.4，2.2) | 2.0(1.3，2.2) | 0.002 | 0.051 |
| 血钾(mmol/L) | 3.7±0.5 | 3.8±0.6 | 0.063 | 0.003 | 3.8±0.6 | 3.8±0.6 | 0.007 | 0.627 |
| 血钠(mmol/L) | 136.3±5.1 | 136.3±4.7 | 0.009 | 0.726 | 136.2±5.7 | 136.3±4.8 | 0.002 | 0.070 |
| AKI诊断前时间(d) | 1.0(0，2.0) | 0(0，1.0) | 0.478 | <0.001 | 0(0，1.0) | 0(0，1.0) | 0.019 | 0.691 |
| AKI分期[例(%)] | 0.091 | <0.001 | 0.027 | 0.651 | ||||
| Ⅰ期 | 6 292(30.6) | 903(26.8) | 936(27.8) | 903(26.9) | ||||
| Ⅱ期 | 10 841(52.7) | 1 821(54.1) | 1 776(52.8) | 1 819(54.1) | ||||
| Ⅲ期 | 3 447(16.7) | 641(19.0) | 649(19.3) | 639(19.0) | ||||
| 注：PSM：倾向性评分匹配法；TTE：经胸超声心动图；AKI：急性肾损伤；TTE组：在诊断AKI 24 h内行TTE检查的患者；No-TTE组：未行TTE检查或首次TTE检查超过24 h的患者；SMD：标准均数差；1 mmHg=0.133 kPa；计量资料符合正态分布采用 |
图1 倾向性评分匹配前后两组患者住院28 d全因病死率的生存分析（Kaplan-Meier生存曲线）注：A：倾向性评分匹配前两组患者住院28 d全因病死率的生存分析；B：倾向性评分匹配后两组患者住院28 d全因病死率的生存分析 |
表2 TTE对AKI住院患者28 d全因病死影响的亚组分析 |
| 项目 | PSM前 | PSM后 | ||||
|---|---|---|---|---|---|---|
| 总数/死亡数(例) | HR(95%CI) | P值 | 总数/死亡数(例) | HR(95%CI) | P值 | |
| 总体 | 23 945/3 045 | 0.80(0.73~0.89) | <0.001 | 6 722/990 | 0.58(0.51~0.65) | <0.001 |
| AKI分期 | ||||||
| Ⅰ期 | 7 195/544 | 0.67(0.51~0.89) | 0.005 | 1 839/157 | 0.50(0.35~0.72) | <0.001 |
| Ⅱ期 | 12 662/1 339 | 0.69(0.58~0.83) | <0.001 | 3 595/464 | 0.55(0.45~0.69) | <0.001 |
| Ⅲ期 | 4 088/1 162 | 0.74(0.62~0.90) | 0.028 | 1 288/369 | 0.72(0.60~0.86) | <0.001 |
| CKD病史 | ||||||
| 无 | 21 060/2 631 | 0.76(0.68~0.86) | <0.001 | 5 681/835 | 0.62(0.54~0.71) | <0.001 |
| 有 | 2 885/414 | 0.71(0.53~0.94) | 0.016 | 1 041/155 | 0.57(0.41~0.80) | 0.001 |
| 肾脏替代治疗 | ||||||
| 无 | 23 590/2 753 | 0.72(0.64~0.81) | <0.001 | 6 607/883 | 0.62(0.54~0.71) | <0.001 |
| 有 | 355/292 | 0.69(0.56~0.92) | 0.011 | 115/107 | 0.59(0.38~0.90) | 0.013 |
| AKI诊断前时间 | ||||||
| 0 d | 8 958/1 126 | 0.60(0.51~0.72) | <0.001 | 3 605/464 | 0.52(0.43~0.63) | <0.001 |
| 1 d | 6 994/891 | 0.75(0.61~0.89) | 0.015 | 1 923/298 | 0.66(0.50~0.87) | 0.003 |
| 2 d | 7 993/1 028 | 0.88(0.71~0.96) | 0.038 | 1 194/228 | 0.70(0.55~0.90) | 0.005 |
| TTE评估次数 | ||||||
| 1次a | 2 816/256 | 0.80(0.72~0.88) | <0.001 | 2 813/252 | 0.61(0.53~0.69) | <0.001 |
| ≥2次b | 549/106 | 0.62(0.55~0.69) | <0.001 | 548/106 | 0.51(0.42~0.62) | <0.001 |
| 注：PSM：倾向性评分匹配法；HR：风险比；95%CI：95%置信区间；AKI：急性肾损伤；CKD：慢性肾脏病；TTE：经胸超声心动图；PSM前后回归分析均校正年龄、性别、体重、AKI诊断前治疗、合并症、重症评分、生命体征（除平均动脉压及心率外）及实验室检查结果（除血红蛋白外）；a：删除AKI诊断24 h内行多次TTE评估的患者；b：删除AKI诊断24 h内仅行一次TTE评估的患者 |
表3 倾向性评分匹配法后两组患者终点事件的比较 |
| 终点事件 | No-TTE组(n=3 361) | TTE组(n=3 361) | t /Z/χ2 | P值 |
|---|---|---|---|---|
| 主要终点事件 | ||||
| 住院28 d全因病死[例(%)] | 632(18.8) | 358(10.7) | 88.932 | <0.001 |
| 次要终点事件 | ||||
| 28 d内无机械通气时间(d) | 26.0±4.8 | 25.6±5.4 | -3.878 | 0.005 |
| 28 d内无血管加压药使用时间(d) | 27.1±2.6 | 26.8±3.1 | -5.534 | <0.001 |
| 28 d内无肾脏替代治疗时间(d) | 27.9±1.1 | 27.8±1.4 | -1.593 | 0.090 |
| 利尿剂[例(%)] | 1 486(44.2) | 1 818(54.1) | 65.609 | <0.001 |
| AKI诊断后第1天静脉输液量(ml) | 700(0，1 000) | 900(0，1 250) | -4.293 | <0.001 |
| AKI诊断后第2天静脉输液量(ml)a | 200(0，250)(n=3 075) | 300(0，400)(n=3 086) | -3.610 | <0.001 |
| AKI诊断后第3天静脉输液量(ml)a | 0(0，100)(n=2 819) | 0(0，150)(n=2 835) | -1.208 | 0.227 |
| AKI诊断后第1天尿量(ml) | 1 400(536，2 100) | 1 500(885，2 736) | -4.591 | <0.001 |
| AKI诊断后第2天尿量(ml)a | 745(370，1 390)(n=3 075) | 760(350，1 410)(n=3 086) | -0.039 | 0.969 |
| AKI诊断后第3天尿量(ml)a | 775(345，1 485)(n=2 819) | 891(517，1 685)(n=2 835) | -2.697 | 0.007 |
| 48 h后血肌酐降低幅度(μmol/L)b | 30.1(14.2，61.9)(n=2 702) | 36.6(23.0，97.2)(n=2 971) | -9.549 | <0.001 |
| ICU住院时间(d) | 5.37(3.77，10.00) | 5.03(3.40，8.90) | -6.589 | <0.001 |
| 住院时间(d) | 11.17(7.21，18.38) | 10.47(6.76，16.94) | -0.155 | 0.877 |
| 注：AKI：急性肾损伤；ICU：重症监护室；TTE：经胸超声心动图；TTE组：在诊断AKI 24 h内行TTE检查的患者；No-TTE组：未行TTE检查或首次TTE检查超过24 h的患者；计量资料符合正态分布时采用 |
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Acute kidney injury (AKI) is defined by a rapid increase in serum creatinine, decrease in urine output, or both. AKI occurs in approximately 10-15% of patients admitted to hospital, while its incidence in intensive care has been reported in more than 50% of patients. Kidney dysfunction or damage can occur over a longer period or follow AKI in a continuum with acute and chronic kidney disease. Biomarkers of kidney injury or stress are new tools for risk assessment and could possibly guide therapy. AKI is not a single disease but rather a loose collection of syndromes as diverse as sepsis, cardiorenal syndrome, and urinary tract obstruction. The approach to a patient with AKI depends on the clinical context and can also vary by resource availability. Although the effectiveness of several widely applied treatments is still controversial, evidence for several interventions, especially when used together, has increased over the past decade.Copyright © 2019 Elsevier Ltd. All rights reserved.
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Acute kidney injury (AKI) is a commonly encountered syndrome associated with various aetiologies and pathophysiological processes leading to decreased kidney function. In addition to retention of waste products, impaired electrolyte homeostasis and altered drug concentrations, AKI induces a generalized inflammatory response that affects distant organs. Full recovery of kidney function is uncommon, which leaves these patients at risk of long-term morbidity and death. Estimates of AKI prevalence range from <1% to 66%. These variations can be explained by not only population differences but also inconsistent use of standardized AKI classification criteria. The aetiology and incidence of AKI also differ between high-income and low-to-middle-income countries. High-income countries show a lower incidence of AKI than do low-to-middle-income countries, where contaminated water and endemic diseases such as malaria contribute to a high burden of AKI. Outcomes of AKI are similar to or more severe than those of patients in high-income countries. In all resource settings, suboptimal early recognition and care of patients with AKI impede their recovery and lead to high mortality, which highlights unmet needs for improved detection and diagnosis of AKI and for efforts to improve care for these patients.
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Intravenous fluid therapy is one of the most common interventions in acutely ill patients. Each day, over 20% of patients in intensive care units (ICUs) receive intravenous fluid resuscitation, and more than 30% receive fluid resuscitation during their first day in the ICU. Virtually all hospitalized patients receive intravenous fluid to maintain hydration and as diluents for drug administration. Until recently, the amount and type of fluids administered were based on a theory described over 100 years ago, much of which is inconsistent with current physiological data and emerging knowledge. Despite their widespread use, various fluids for intravenous administration have entered clinical practice without a robust evaluation of their safety and efficacy. High-quality, investigator-initiated studies have revealed that some of these fluids have unacceptable toxicity; as a result, several have been withdrawn from the market (while others, controversially, are still in use). The belief that dehydration and hypovolaemia can cause or worsen kidney and other vital organ injury has resulted in liberal approaches to fluid therapy and the view that fluid overload and tissue oedema are 'normal' during critical illness; this is quite possibly harming patients. Increasing evidence indicates that restrictive fluid strategies might improve outcomes.
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To describe the potential impact of different fluid management strategies on renal outcomes in critically ill and postoperative patients.Uncritical fluid administration may induce renal compartment syndrome and renal venous congestion, which contribute to kidney dysfunction. In more than 5000 randomized surgical or septic patients, goal-directed therapy did not reduce fluid accumulation, acute kidney injury (AKI) development or need for renal replacement therapy. In contrast to synthetic colloids, which increase the risk of AKI, albumin solutions and balanced crystalloids appear well tolerated from a renal standpoint in medical and surgical patients requiring intensive care. However, any clinical benefits compared with 0.9% sodium chloride have not yet been demonstrated.Although synthetic colloids should be avoided in patients with or at risk of AKI, the renal efficacy of using albumin solutions and/or balanced crystalloids as alternatives to 0.9% sodium chloride in high-risk patients is yet to be confirmed or refuted. Improved goal-directed protocols, which minimize unnecessary fluid administration and reduce potentially harmful effects of fluid overload, need to be developed and tested.
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To establish evidence-based guidelines for the use of bedside cardiac ultrasound, echocardiography, in the ICU and equivalent care sites.Grading of Recommendations, Assessment, Development and Evaluation system was used to rank the "levels" of quality of evidence into high (A), moderate (B), or low (C) and to determine the "strength" of recommendations as either strong (strength class 1) or conditional/weak (strength class 2), thus generating six "grades" of recommendations (1A-1B-1C-2A-2B-2C). Grading of Recommendations, Assessment, Development and Evaluation was used for all questions with clinically relevant outcomes. RAND Appropriateness Method, incorporating the modified Delphi technique, was used in formulating recommendations related to terminology or definitions or in those based purely on expert consensus. The process was conducted by teleconference and electronic-based discussion, following clear rules for establishing consensus and agreement/disagreement. Individual panel members provided full disclosure and were judged to be free of any commercial bias.Forty-five statements were considered. Among these statements, six did not achieve agreement based on RAND appropriateness method rules (majority of at least 70%). Fifteen statements were approved as conditional recommendations (strength class 2). The rest (24 statements) were approved as strong recommendations (strength class 1). Each recommendation was also linked to its level of quality of evidence and the required level of echo expertise of the intensivist. Key recommendations, listed by category, included the use of cardiac ultrasonography to assess preload responsiveness in mechanically ventilated (1B) patients, left ventricular (LV) systolic (1C) and diastolic (2C) function, acute cor pulmonale (ACP) (1C), pulmonary hypertension (1B), symptomatic pulmonary embolism (PE) (1C), right ventricular (RV) infarct (1C), the efficacy of fluid resuscitation (1C) and inotropic therapy (2C), presence of RV dysfunction (2C) in septic shock, the reason for cardiac arrest to assist in cardiopulmonary resuscitation (1B-2C depending on rhythm), status in acute coronary syndromes (ACS) (1C), the presence of pericardial effusion (1C), cardiac tamponade (1B), valvular dysfunction (1C), endocarditis in native (2C) or mechanical valves (1B), great vessel disease and injury (2C), penetrating chest trauma (1C) and for use of contrast (1B-2C depending on indication). Finally, several recommendations were made regarding the use of bedside cardiac ultrasound in pediatric patients ranging from 1B for preload responsiveness to no recommendation for RV dysfunction.There was strong agreement among a large cohort of international experts regarding several class 1 recommendations for the use of bedside cardiac ultrasound, echocardiography, in the ICU. Evidence-based recommendations regarding the appropriate use of this technology are a step toward improving patient outcomes in relevant patients and guiding appropriate integration of ultrasound into critical care practice.
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Circulatory shock is a life-threatening syndrome resulting in multiorgan failure and a high mortality rate. The aim of this consensus is to provide support to the bedside clinician regarding the diagnosis, management and monitoring of shock.The European Society of Intensive Care Medicine invited 12 experts to form a Task Force to update a previous consensus (Antonelli et al.: Intensive Care Med 33:575-590, 2007). The same five questions addressed in the earlier consensus were used as the outline for the literature search and review, with the aim of the Task Force to produce statements based on the available literature and evidence. These questions were: (1) What are the epidemiologic and pathophysiologic features of shock in the intensive care unit? (2) Should we monitor preload and fluid responsiveness in shock? (3) How and when should we monitor stroke volume or cardiac output in shock? (4) What markers of the regional and microcirculation can be monitored, and how can cellular function be assessed in shock? (5) What is the evidence for using hemodynamic monitoring to direct therapy in shock? Four types of statements were used: definition, recommendation, best practice and statement of fact.Forty-four statements were made. The main new statements include: (1) statements on individualizing blood pressure targets; (2) statements on the assessment and prediction of fluid responsiveness; (3) statements on the use of echocardiography and hemodynamic monitoring.This consensus provides 44 statements that can be used at the bedside to diagnose, treat and monitor patients with shock.
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| [11] |
To assess the current practice of propensity score (PS) analysis in the medical literature, particularly the assessment and reporting of balance on confounders.A PubMed search identified studies using PS methods from December 2011 through May 2012. For each article included in the review, information was extracted on important aspects of the PS such as the type of PS method used, variable selection for PS model, and assessment of balance.Among 296 articles that were included in the review, variable selection for PS model was explicitly reported in 102 studies (34.4%). Covariate balance was checked and reported in 177 studies (59.8%). P-values were the most commonly used statistical tools to report balance (125 of 177, 70.6%). The standardized difference and graphical displays were reported in 45 (25.4%) and 11 (6.2%) articles, respectively. Matching on the PS was the most commonly used approach to control for confounding (68.9%), followed by PS adjustment (20.9%), PS stratification (13.9%), and inverse probability of treatment weighting (IPTW, 7.1%). Balance was more often checked in articles using PS matching and IPTW, 70.6% and 71.4%, respectively.The execution and reporting of covariate selection and assessment of balance is far from optimal. Recommendations on reporting of PS analysis are provided to allow better appraisal of the validity of PS-based studies.Copyright © 2015 Elsevier Inc. All rights reserved.
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| [12] |
To provide an update to "Surviving Sepsis Campaign Guidelines for Management of Sepsis and Septic Shock: 2012".A consensus committee of 55 international experts representing 25 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. A stand-alone meeting was held for all panel members in December 2015. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development.The panel consisted of five sections: hemodynamics, infection, adjunctive therapies, metabolic, and ventilation. Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Each subgroup generated a list of questions, searched for best available evidence, and then followed the principles of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to assess the quality of evidence from high to very low, and to formulate recommendations as strong or weak, or best practice statement when applicable.The Surviving Sepsis Guideline panel provided 93 statements on early management and resuscitation of patients with sepsis or septic shock. Overall, 32 were strong recommendations, 39 were weak recommendations, and 18 were best-practice statements. No recommendation was provided for four questions.Substantial agreement exists among a large cohort of international experts regarding many strong recommendations for the best care of patients with sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for these critically ill patients with high mortality.
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| [13] |
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| [14] |
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| [15] |
Central venous pressure (CVP) has been shown to have poor predictive value for fluid responsiveness in critically ill patients. We aimed to re-evaluate this in a larger sample subgrouped by baseline CVP values.In April 2015, we systematically searched and included all clinical studies evaluating the value of CVP in predicting fluid responsiveness. We contacted investigators for patient data sets. We subgrouped data as lower (<8 mmHg), intermediate (8-12 mmHg) and higher (>12 mmHg) baseline CVP.We included 51 studies; in the majority, mean/median CVP values were in the intermediate range (8-12 mmHg) in both fluid responders and non-responders. In an analysis of patient data sets (n = 1148) from 22 studies, the area under the receiver operating curve was above 0.50 in the <8 mmHg CVP group [0.57 (95% CI 0.52-0.62)] in contrast to the 8-12 mmHg and >12 mmHg CVP groups in which the lower 95% CI crossed 0.50. We identified some positive and negative predictive value for fluid responsiveness for specific low and high values of CVP, respectively, but none of the predictive values were above 66% for any CVPs from 0 to 20 mmHg. There were less data on higher CVPs, in particular >15 mmHg, making the estimates on predictive values less precise for higher CVP.Most studies evaluating fluid responsiveness reported mean/median CVP values in the intermediate range of 8-12 mmHg both in responders and non-responders. In a re-analysis of 1148 patient data sets, specific lower and higher CVP values had some positive and negative predictive value for fluid responsiveness, respectively, but predictive values were low for all specific CVP values assessed.
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| [16] |
Despite a previous meta-analysis that concluded that central venous pressure should not be used to make clinical decisions regarding fluid management, central venous pressure continues to be recommended for this purpose.To perform an updated meta-analysis incorporating recent studies that investigated indices predictive of fluid responsiveness. A priori subgroup analysis was planned according to the location where the study was performed (ICU or operating room).MEDLINE, EMBASE, Cochrane Register of Controlled Trials, and citation review of relevant primary and review articles.Clinical trials that reported the correlation coefficient or area under the receiver operating characteristic curve (AUC) between the central venous pressure and change in cardiac performance following an intervention that altered cardiac preload. From 191 articles screened, 43 studies met our inclusion criteria and were included for data extraction. The studies included human adult subjects, and included healthy controls (n = 1) and ICU (n = 22) and operating room (n = 20) patients.Data were abstracted on study characteristics, patient population, baseline central venous pressure, the correlation coefficient, and/or the AUC between central venous pressure and change in stroke volume index/cardiac index and the percentage of fluid responders. Meta-analytic techniques were used to summarize the data.Overall 57% ± 13% of patients were fluid responders. The summary AUC was 0.56 (95% CI, 0.54-0.58) with no heterogenicity between studies. The summary AUC was 0.56 (95% CI, 0.52-0.60) for those studies done in the ICU and 0.56 (95% CI, 0.54-0.58) for those done in the operating room. The summary correlation coefficient between the baseline central venous pressure and change in stroke volume index/cardiac index was 0.18 (95% CI, 0.1-0.25), being 0.28 (95% CI, 0.16-0.40) in the ICU patients, and 0.11 (95% CI, 0.02-0.21) in the operating room patients.There are no data to support the widespread practice of using central venous pressure to guide fluid therapy. This approach to fluid resuscitation should be abandoned.
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| [19] |
Resuscitation of critically ill trauma patients can be precarious, and errors can cause acute kidney injuries. If renal failure develops, continuous renal replacement therapy (CRRT) may be necessary, but adds expense. Hemodynamic transesophageal echocardiography (hTEE) provides objective data to guide resuscitation. We hypothesized that hTEE use improved acute kidney injury (AKI) management, reserved CRRT use for more severe AKIs, and decreased cost and resource utilization. We retrospectively reviewed 2413 trauma patients admitted to a Level I trauma center's ICU between 2009 and 2015. Twenty-three patients required CRRT before standard hTEE use and 11 required CRRT after; these are the "CRRT" and "CRRT/hTEE" groups, respectively. The hTEE group comprised 83 patients evaluated with hTEE, with AKI managed without CRRT. We compared the average creatinine, change in creatinine, and Acute Kidney Injury Network (AKIN) of "CRRT" with "CRRT/hTEE" and "hTEE." We also analyzed several quality measures including ICU length of stay and cost. "CRRT" had a lower AKIN score (1.6) than "CRRT/hTEE" (2.9) ( = 0.0003). "hTEE" had an AKIN score of 2.1 ( = 0.0387). "CRRT" also had increased ICU days (25.1) compared with "CRRT/hTEE" (20.2) ( = 0.014) and "hTEE" (16.8) ( = 0.003). "CRRT" accrued on average
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胡玉刚：课题设计、论文撰写；王浩、杨远婷、陈粤瑛、余芬：数据整理、统计学分析；周青：研究指导、论文修改
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