Hypertonic versus near isotonic crystalloid for fluid resuscitation in critically ill patients

  • Review
  • Intervention

Authors


Abstract

Background

Hypertonic solutions are considered to have a greater ability to expand blood volume and thus elevate blood pressure and can be administered as a small volume infusion over a short time period. On the other hand, the use of hypertonic solutions for volume replacement may also have important disadvantages.

Objectives

To determine whether hypertonic crystalloid decreases mortality in patients with hypovolaemia.

Search methods

We searched the Cochrane Injuries Group's specialised register, MEDLINE, EMBASE, The Cochrane Library, issue 3, 2007, The National Research Register issue 3, 2007 and the British Library's Electronic Table of Contents ZETOC. We also checked reference lists of all articles identified. The searches were last updated in October 2007

Selection criteria

Randomised trials comparing hypertonic to isotonic and near isotonic crystalloid in patients with trauma or burns or who were undergoing surgery.

Data collection and analysis

Two authors independently extracted the data and assessed the quality of the trials.

Main results

Fourteen trials with a total of 956 participants are included in the meta-analysis. The pooled relative risk (RR) for death in trauma patients was 0.84 (95% confidence interval [CI] 0.69 to1.04); in patients with burns 1.49 (95% CI 0.56 to 3.95); and in patients undergoing surgery 0.51 (95% CI 0.09 to 2.73). In the one trial that gave data on disability using the Glasgow outcome scale, the relative risk for a poor outcome was 1.00 (95% CI 0.82 to 1.22).

Authors' conclusions

This review does not give us enough data to be able to say whether hypertonic crystalloid is better than isotonic and near isotonic crystalloid for the resuscitation of patients with trauma or burns, or those undergoing surgery. However, the confidence intervals are wide and do not exclude clinically significant differences. Further trials which clearly state the type and amount of fluid used and that are large enough to detect a clinically important difference are needed.

摘要

背景

高張溶液和等張溶液相比,在病危病患輸液復甦治療上的療效比較

一般認為,短時間注入少量的高張溶液,可以有效的增加血液容積並提升血壓。但同時,高張溶液的輸液治療,有其無可避免的缺點。

目標

高張容積的輸液治療,是否可以有效減低低血容積病患的死亡率。

搜尋策略

搜尋MEDLINE,EMBASE,The Cochrane Controlled Trials Register Injuries Group的研究及其參考文獻,和國家研究登記名冊。我們確認所有文章的參考文獻並檢索National Research Register。

選擇標準

隨機抽樣試驗,比較高張溶液和等張溶液,用在外傷,燒燙傷及手術病患上的療效。

資料收集與分析

兩名作者分別摘錄資料並評估試驗品質。

主要結論

整合分析(metaanalysis)包含了14個實驗當,總共956位受試者。對外傷病人而言,高張輸液的相對風險(relative risk)是0.84倍(95% confidence interval [CI]為0.69 – 1.04),對燒傷病人是1.49倍(95% CI為0.56 – 3.95),對手術病患是0.51倍(95% CI為0.09至2.73)。其中一個研究用Glasgow outcome scale分析日後失能的相對風險是1.00(95% CI為0.82至1.22)。

作者結論

這篇回顧性的文章沒有足夠的證據,支持高張溶液用在外傷,燒燙傷及手術病患上比等張溶液有效。但信賴區間很寬(confidence intervals),無法排除其中有些具有臨床意義。期待將來的研究能更清楚的分析輸液的種類,輸液量,並且提供足夠大的樣本數,以得到真正臨床上的差異。

翻譯人

本摘要由高雄榮民總醫院金沁琳翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

目前還沒有足夠的證據,證實對大量失血的病患而言,究竟哪種晶體輸液(crystalloids)能達到最好的效果。某些輸液中含有物質,稱為“晶體輸液”(crystalloids),而晶體輸液的濃度應該與人體血液大約相同(“等張”)或較高(“高張”)呢?雖然一般認為高張溶液能有效的增加血液容積並提升血壓,但也伴隨著許多缺點。作者對這個議題做了系統性的文獻回顧,發現就目前已有的資料,並沒有足夠的證據下一個完整的結論,有待未來更多的研究。

Plain language summary

More evidence needed as to the best concentration of crystalloid to use in resuscitation fluids

Fluid resuscitation is usually given when a patient has lost a lot of blood, but there is continuing uncertainty as to the best sort of fluid to use. Some of the fluids used contain substances classified as "crystalloids", but should the concentration of crystalloids in the fluid be about the same as their concentration in human blood ("isotonic") or higher ("hypertonic")? It is commonly believed that hypertonic crystalloid is the more effective at increasing blood volume but that there could be some disadvantages to using it. This review has assessed the evidence from studies that compared the use of the two types of fluid with patients who had been injured or burned, or were having surgery. Not enough evidence is available, however, to decide which crystalloid concentration is best. More research is needed.