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JAMA:氧浓度越高越好?危重病人器官功能障碍时怎么选氧浓度?

2021-09-04 MedSci原创 MedSci原创

在多器官功能衰竭危重病人中,与高Pao2正常值目标相比,低Pao2正常值目标的治疗并没有导致器官功能障碍的统计学上的明显减少。

在重症监护室(ICU)中,通常会大量给氧以治疗或预防低氧血症。多年来,氧气被认为具有持续的有利影响。然而,一项使用1999-2006年数据的观察性研究显示,Pao2与死亡率之间呈U型关系-,从而开启了关于危重病人最佳氧合目标的辩论。

高氧血症的潜在负面影响包括肺部毒性,加重缺血/再灌注损伤,以及全身血管收缩导致器官灌注减少,这些影响可能会损害而不是改善组织的氧输送。全身血管收缩可以减少全身炎症反应综合征(SIRS)患者的血管扩张,有利于重新分配器官的血流。

在ICU患者中进行的6项随机临床试验(RCTs)和1项荟萃分析对低氧与高氧目标进行了比较,结果并不一致。其中两项试验和荟萃分析报告了低氧饱和度目标的死亡率降低,而4项试验结果没有差异。此外,一项试验报告了低氧饱和度目标组中肠系膜缺血的发生率增加。

为了确定低正常Pao2目标与高正常目标相比,是否能减少SIRS重症患者的器官功能障碍,来自荷兰阿姆斯特丹心血管科学部、阿姆斯特丹感染免疫研究所的专家开展了多项随机对照试验,结果发表在近期JAMA杂志上。

研究人员在荷兰的4个重症监护室进行多中心随机临床试验。入选时间为2015年2月至2018年10月,随访结束时间为2019年1月,包括有2个以上器官损害且预计住院时间超过48小时的入院成年患者。共有9925名患者接受了资格筛选,其中574人符合入组标准并被随机分配。

目标Pao2范围为8至12千帕(低-正常,n = 205)和14至18千帕(高-正常,n = 195)。主要终点是SOFARANK,这是一个非呼吸器官衰竭的排名结果,由顺序器官衰竭评估(SOFA)得分中的非呼吸部分量化,在前14个研究日中进行汇总。参与者从器官衰竭改善最快(最低分)到器官衰竭恶化或死亡(最高分)进行排名。次要终点是机械通气时间、院内死亡率和低氧测量。

在574名随机入组的患者中,400名(70%)在24小时内入组(中位年龄,68岁;140名女性[35%]),所有患者都完成了试验。各组之间的Pao2中位数差异为-1.93千帕(95%CI,-2.12~-1.74;P < .001)。

在重症监护室第1至15天活着的病人按治疗组的Pao2值

结果显示,低正常Pao2组的SOFARANK评分中位数为-35分,高正常Pao2组为-40分(中位数差异=10,95%CI:0-21)。机械通气的中位时间(3.4天 vs 3.1天;中位差异=-0.15,95%CI:-0.88~0.47)和院内死亡率(32% vs 31%;OR=1.04,95%CI:0.67-1.63)没有显著差异。

同时,轻度缺氧在低正常值组更经常发生(1.9% vs 1.2%;中位数差异=0.73,95% CI:0.30- 1.20)。低正常Pao2组有20名患者(10%)和高正常Pao2组有21名患者(11%)出现急性肾衰竭,低正常Pao2组有6名患者(2.9%)和高正常Pao2组有7名患者(3.6%)出现急性心肌梗塞。

按治疗组划分的SOFARANK结果累积值

综上,在多器官功能衰竭危重病人中,与高Pao2正常值目标相比,低Pao2正常值目标的治疗并没有导致器官功能障碍的统计学上的明显减少。

 

参考文献:

Effect of Low-Normal vs High-Normal Oxygenation Targets on Organ Dysfunction in Critically Ill PatientsA Randomized Clinical TrialJAMA. Published online August 31, 2021. doi:10.1001/jama.2021.13011

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    2021-09-04 旺医

    顶刊就是顶刊,谢谢梅斯带来这么高水平的研究报道,我们科里同事经常看梅斯,分享梅斯上的信息

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由此可见,虽然吸入氧气较为常见,但是并无重要的临床益处。从八个RCTs的结果支持从血氧正常的患者在临床实践中停止吸入氧气。

NEJM:疑似心肌梗死患者的氧疗收益研究

研究认为,对于未出现血氧不足的疑似心肌梗死患者进行持续氧疗不会降低患者1年内的心梗复发风险

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