脑钠肽指导机械通气撤机困难危重病患者的液体管理

目的 探讨在机械通气撤机困难的危重病患者中应用脑钠肽(BNP)指导液体管理的临床价值.方法 采用前瞻性随机对照研究,选择2013年1月至2015年12月期间海南医学院第二附属医院重症医学科收治的76例撤机困难患者,以随机数表法分为常规治疗组和BNP指导组.BNP指导组:当BNP≥200 pg/mL时,利用利尿剂进行液体管理(-1000~-500 mL/d);常规治疗组不常规给予利尿剂控制液体负平衡,由临床医生决定.比较两组患者撤机期间的液体平衡量、BNP变化、并发症(如呼吸机相关性肺炎、心律失常、急性肾损伤、电解质紊乱)、成功撤机时间、ICU停留时间、ICU死亡率.结果 BNP指导组撤机期间液体平均平衡量明显少于常规治疗组,差异有统计学意义[-442.5(-797.25,147.25)mL vs-79.5(-356.25,378.50)mL,P=0.007].和常规治疗组比较,BNP指导组的成功拔管时间明显缩短,差异有统计学意义[59.5(23.2,140.7)h vs 39.4(21.5,108.3)h,P=0.035],分组后28 d内非机械通气时间明显增多,差异有统计学意义[23.0(20.0,25.0)d vs 25.0(22.0,26.0)d,P=0.032];ICU停留时间(P=0.777)、ICU死亡率(P=0.723)差异无统计学意义.两组患者并发症中呼吸机相关性肺炎发生率(P=0.032)、重新接受机械通气率(P=0.043)差异有统计学意义,再插管率(P=0.376)、心律失常发生率(P=0.497)、MAP≤65 mmHg(P=0.175)、急性肾损伤发生率(P=0.287)、钾异常(P=0.105)、钠异常(P=0.361)差异无统计学意义.结论 在机械通气撤机困难的危重病患者中,脑钠肽指导液体管理可以缩短撤机时间,不增加不良事件发生率.

B-type natriuretic peptide guided fluid management in critical patients with difficult weaning from mechanical ventilation

Objective To investigate the value of B-type natriuretic peptide (BNP) guided fluid management in critical patients with difficult weaning from mechanical ventilation. Methods In a prospective randomized controlled trial, 76 patients with difficult wearing from mechanical ventilation in ICU in our hospital were included from January 2013 to December 2015, and the patients were divided into BNP-guided group and conventional treatment group. In the BNP-guided group, furosemide was administered for fluid management (-1000 mL/d to-500 mL/d) when the BNP lev-el was no less than 200 pg/mL. In the conventional treatment group, all treatments were performed according to usual care. Baseline indexes of two groups were compared, including the average daily fluid balance, changes of BNP, and complications during weaning (ventilator-associated pneumonia, arrhythmia, acute kidney injury, electrolyte distur-bance), time to successful weaning, ICU stay time, ICU mortality. Results Compared with the conventional treatment group, the BNP-guided group had more negative fluid balance during the weaning period,-442.5 (-797.25, 147.25) mL vs-79.5 (-356.25, 378.5) mL, P=0.007. The time to successful extubation was significantly shorter in the BNP-guided group than in the conventional treatment group, 59.5 (23.2, 140.7) h vs 39.4 (21.5, 108.3) h, P=0.035, and the ventila-tor-free duration from randomization to Day 28 was significantly longer, 23 (20, 25) d vs 25 (22, 26) d, P=0.032. No dif-ference was found for length of ICU stay (P=0.777) and ICU mortality (P=0.723). There were statistically significant dif-ferences in the rate of ventilator-associated pneumonia (P=0.032), requiring re-ventilation with mechanical ventilation (P=0.043) between the two groups, but there were no significant between-group differences in the percentages of pa-tients with re-intubation (P=0.376), arrhythmia (P=0.497), mean arterial pressure≤65 mmHg (P=0.175), acute kidney injury (P=0.287), hypokalemia (P=0.105), hypernatremia (P=0.361). Conclusion In critical patients with difficult weaning from mechanical ventilation, BNP-guided fluid management shortens the duration of weaning, without increas-ing adverse events.