优化的液体治疗策略对感染性休克患者预后影响的系统评价

目的 系统评价血流动力学优化的液体治疗策略对感染性休克患者预后的影响.方法 通过检索美国《医学索引》(MEDLINE)、Cochrane临床试验数据库、生物医学与药理学文摘数据库(Embase)、荷兰《医学文摘》、中国生物医学文献数据库(CBM)和中国期刊网全文数据库(CNKI)等文献数据库,收集全世界范围内采用有效的液体治疗策略治疗严重脓毒症和感染性休克患者的随机对照临床试验(RCT)相关文献.试验组按血流动力学监测完成最佳血流动力学复苏终点目标,对照组予常规治疗;两组再依据干预的时间不同分为早期组(6～24h完成目标性液体治疗)和晚期组(不清楚开始时间或＞24 h完成目标性液体治疗)进行亚组分析.按Cochrane系统评价方法筛选试验、评价质量、提取资料,采用RevMan 5.0软件进行Meta分析.结果 纳入合格文献11篇、共计研究对象2066例患者,合并结果显示:优化的液体治疗策略能降低患者的病死率[Peto比值比(OR)=0.63,95％可信区间(95％CI)0.48～0.84,P=0.002],各试验组间在统计学上存在异质性(P=0.01,I2=55％).早期优化液体治疗策略对病死率的研究(n=8)具有较小的异质性( P=0.44,I2=0％);试验组较对照组更能显著降低患者病死率(OR=0.53,95％CI 0.42～0.66,P＜0.000 01)和多器官功能障碍综合征(MODS)发生率(OR=0.61,95％CI0.43～0.85,P=0.004).晚期液体治疗对病死率的研究(n=3)存在异质性(P=0.05,I2=66％);试验组与对照组病死率(OR=0.89, 95％CI 0.52～1.54,P=0.68)和MODS发生率(OR=0.43,95％CI0.17～ 1.08,P=0.07)比较差异无统计学意义.结论 早期应用血流动力学最优化的液体治疗策略能降低感染性休克患者的病死率及MODS的发生率.

The effect of an optimized resuscitation strategy on prognosis of patients with septic shock: a systematic review

Objective To determine the treatment effect of an optimized resuscitation strategy on prognosis of patients with septic shock.Methods A systematic review of MEDLINE,the Cochrane Library,Embase,CBM,CNKI and other sources using a comprehensive strategy was conducted.All randomized controlled trials (RCTs) of treatment of severe sepsis and septic shock were included.The patients were randomized into treatment group and control group.Preplanned subgroup analysis required studies to be categorized based on early (goal-directed therapy accomplished within 6-24 hours ) vs.late (initiated after 24 hours or unknown time of resuscitation implementation).Two authors independently extracted data and assessed study quality using standardized methods.Consensus was reached by conference.The Cochrance Collaboration's software RevMan 5.0 was used for data analysis.Results Eleven studies were included in the final analysis,providing a sample of 2066 patients.The combined results demonstrated a decrease in mortality [ odds ratio (OR) =0.63,95％ confidence interval (95％ CI) 0.48-0.84,P=0.002 ] ; however,there was statistically significant heterogeneity (P=0.01,I2=55％ ).Among the early optimal resuscitation studies (n=8) there was minimal heterogeneity (P=0.44,I2=0％) and a significant decrease in mortality (OR=0.53,95％CI0.42-0.66,P＜0.000 01 ) and incidence of multiple organ dysfunction syndrome (MODS,OR =0.61,95％ CI0.43-0.85,P=0.004).For the late resuscitation studies (n=3),there was statistically significant difference (P=0.05,I2=66％ ),and there was no significant effect on mortality (OR=0.89,95％CI 0.52-1.54,P=0.68 ) and incidence of MODS (OR=0.43,95％CI 0.17-1.08,P=0.07).Conclusion This meta-analysis found that the application of an early optimal resuscitation strategy to patients with septic shock imparts a significant reduction in mortality and incidence of MODS.