目的:评估两种液体复苏方案的疗效差异,单独使用晶体与血浆输注的晶体相比,低白蛋白血症对脓毒症患者预后的影响.
方法:进行回顾性研究。选取2017年1月至2022年12月东台市人民医院重症医学科收治的脓毒症低蛋白血症患者为研究对象。根据入院时的液体复苏方案,将患者分为单一组(单纯晶体)和联合组(晶体联合血浆)。一般信息,收集复苏前(第1天)和复苏第3天的凝血指标。主要研究终点是28天死亡率。根据复苏时的白蛋白水平(<25g/L,25-30g/L,和>30g/L)比较不同白蛋白水平患者28天死亡率的差异。绘制患者28天预后的Kaplan-Meier存活曲线。
结果:共纳入164例低白蛋白血症的脓毒症患者,其中单组60例,联合组104例。(1)年龄差异无显著性,性别,急性生理学和慢性健康评估II(APACHEII),序贯器官衰竭评估(SOFA),以及复苏前血小板计数(PLT),凝血酶原时间(PT),活化部分凝血活酶时间(APTT),D-二聚体,抗凝血酶-III(AT-III),国际标准化比率(INR),纤维蛋白降解产物(FDP),血清乳酸(Lac),两组之间的白蛋白水平,表明可比性。(2)联合组的PT和AT-III水平在第3天较复苏前显著改善,与单一组相比,联合组的AT-III水平在第3天改善更明显[(79.80±17.95)%vs.(66.67±18.69)%,P<0.01]。在单组和联合组复苏后,Lac和白蛋白水平显着改善。但两组改善程度无显著差异。(3)单组和联合组的28天死亡率没有显着差异[55.0%(33/60)。42.3%(44/104),P>0.05]。白蛋白<25g/L患者的28天死亡率明显高于白蛋白25-30g/L和>30g/L患者[63.1%(41/65)vs.36.2%(25/69),36.7%(11/30),均P<0.05]。(4)Kaplan-Meier生存曲线分析显示,单组与联合组28天累积生存率差异无统计学意义(Log-Rank:χ2=2.067,P=0.151)。单一组白蛋白的中位生存率为27.1g/L[95%置信区间(95CI)为24.203-29.997],联合组为28.7g/L(95CI为26.065-31.335)。
结论:晶体联合血浆液体复苏可改善低白蛋白血症脓毒症患者的外源性凝血功能障碍,但不能改善28天死亡率结局.脓毒症患者的初始白蛋白水平越高,死亡率越低。
OBJECTIVE: To evaluate the difference in efficacy of two fluid resuscitation regimens, crystalloid alone versus crystalloid combined with plasma infusion, on the prognosis of septic patients with hypoalbuminemia.
METHODS: A retrospective study was conducted. Septic patients with hypoalbuminemia admitted to the department of critical care medicine of Dongtai People\'s Hospital from January 2017 to December 2022 were selected as study subjects. Patients were divided into single group (crystalloid alone) and combined group (crystalloid combined with plasma) according to the fluid resuscitation regimen at the time of admission. General information, as well as coagulation indices before resuscitation (on day 1) and day 3 of resuscitation were collected. The primary study endpoint was 28-day mortality. The single and combined groups were stratified according to albumin level at resuscitation (< 25 g/L, 25-30 g/L, and > 30 g/L) to compare the differences in 28-day mortality among patients with different albumin levels. Kaplan-Meier survival curves of patients\' 28-day prognosis were plotted.
RESULTS: A total of 164 septic patients with hypoalbuminemia were included, including 60 patients in the single group and 104 patients in the combined group. (1) There were no significantly differences in age, gender, acute physiology and chronic health evaluation II (APACHE II), sequential organ failure assessment (SOFA), as well as pre-resuscitation platelet count (PLT), prothrombin time (PT), activated partial thromboplastin time (APTT), D-dimer, antithrombin- III (AT- III), international normalized ratio (INR), fibrin degradation product (FDP), serum lactic acid (Lac), and albumin level between the two groups, indicating comparability. (2) The levels of PT and AT- III in the combined group improved significantly on day 3 compared to before resuscitation, and the level of AT- III in the combined group improved more significantly on day 3 compared to the single group [(79.80±17.95)% vs. (66.67±18.69)%, P < 0.01]. Lac and albumin levels improved significantly after resuscitation in both the single and combined groups, but there were no significantly differences in the degree of improvement between the two groups. (3) There was no significantly difference in the 28-day mortality between the single group and the combined group [55.0% (33/60) vs. 42.3% (44/104), P > 0.05]. The 28-day mortality of patients with albumin < 25 g/L was significantly higher than that with albumin 25-30 g/L and > 30 g/L [63.1% (41/65) vs. 36.2% (25/69), 36.7% (11/30), both P < 0.05]. (4) Kaplan-Meier survival curve analysis showed that there was no significantly difference in 28-day cumulative survival rate between the single group and the combined group (Log-Rank: χ 2 = 2.067,P = 0.151). The median survival rate of albumin was 27.1 g/L [95% confidence interval (95%CI) was 24.203-29.997] in the single group and 28.7 g/L (95%CI was 26.065-31.335) in the combined group.
CONCLUSIONS: Fluid resuscitation with crystalloid combined with plasma improves exogenous coagulation dysfunction in septic patients with hypoalbuminemia, but does not improve 28-day mortality outcome. The higher the initial albumin level in septic patients, the lower the mortality.