2024+ESICM临床实践指南：成人危重患者的液体治疗—第1部分：复苏液体的选择.pdf

Intensive Care Medhttps:/doi.org/10.1007/s00134-024-07369-9GUIDELINESEuropean Society ofIntensive Care Medicine clinical practice guideline onfluid therapy inadult critically ill patients.Part 1:the choice ofresuscitation fluidsYaseen M.Arabi1*,Emilie BelleyCote2,Andrea Carsetti3,Daniel De Backer4,Katia Donadello5,6,Nicole P.Juffermans7,Naomi Hammond8,9,Jon Henrik Laake10,Dawei Liu11,Kathryn Maitland12,Antonio Messina13,14,Morten Hylander Mller15,16,Daniele Poole17,Rob Mac Sweeney18,JeanLouis Vincent19,Fernando G.Zampieri20 and Fayez AlShamsi21 on behalf of European Society of Intensive Care Medicine 2024 SpringerVerlag GmbH Germany,part of Springer NatureAbstract Purpose:This is the first of three parts of the clinical practice guideline from the European Society of Intensive Care Medicine(ESICM)on resuscitation fluids in adult critically ill patients.This part addresses fluid choice and the other two will separately address fluid amount and fluid removal.Methods:This guideline was formulated by an international panel of clinical experts and methodologists.The Grading of Recommendations Assessment,Development,and Evaluation(GRADE)methodology was applied to evaluate the certainty of evidence and to move from evidence to decision.Results:For volume expansion,the guideline provides conditional recommendations for using crystalloids rather than albumin in critically ill patients in general(moderate certainty of evidence),in patients with sepsis(moderate certainty of evidence),in patients with acute respiratory failure(very low certainty of evidence)and in patients in the perioperative period and patients at risk for bleeding(very low certainty of evidence).There is a conditional recommendation for using isotonic saline rather than albumin in patients with traumatic brain injury(very low certainty of evidence).There is a conditional recommendation for using albumin rather than crystalloids in patients with cirrhosis(very low certainty of evidence).The guideline provides conditional recommendations for using balanced crystalloids rather than isotonic saline in critically ill patients in general(low certainty of evidence),in patients with sepsis(low certainty of evidence)and in patients with kidney injury(very low certainty of evidence).There is a conditional recommendation for using isotonic saline rather than balanced crystalloids in patients with traumatic brain injury(very low certainty of evidence).There is a conditional recommendation for using isotonic crystalloids rather than smallvolume hypertonic crystalloids in critically ill patients in general(very low certainty of evidence).*Correspondence:arabimngha.med.sa 1 Intensive Care Department,King Abdulaziz Medical City,Ministry of National GuardHealth Affairs,King Abdullah International Medical Research Center,College of Medicine,King Saud Bin Abdulaziz University for Health Sciences,Riyadh,Saudi ArabiaFull author information is available at the end of the articleConclusions:This guideline provides eleven recommendations to inform clinicians on resuscitation fluid choice in critically ill patients.Keywords:Albumin,Crystalloid solutions,Colloid solutions,Practice guidelines,Critical care,Fluid therapyIntroductionAdministration of resuscitation fluids is common in the management of critically ill patients 1.The European Society of Intensive Care Medicine(ESICM)convened a group of content and method experts to issue a clini-cal practice guideline(CPG)on fluid management in adult critically ill patients.This CPG was divided into three parts:the choice of resuscitation fluids(part 1),the amount of resuscitation fluids(part 2),and fluid removal in the de-escalation phase(part 3).The full list of contrib-utors is presented in the online electronic supplementary material(ESM).In this manuscript,the guideline on the choice of resuscitation fluid will be presented.Resuscitation fluids are categorized into crystalloids,including isotonic saline and balanced crystalloids,and colloids,with albumin as the reference colloid solution 2.In clinical practice,the choice of resuscitation fluids varies according to fluid availability,understanding of the physiologic characteristics of different fluids,clinician preferences,practice setting and region 3.The aim of this CPG from ESICM was to provide evi-dence-based guidance regarding the choice of resusci-tation fluid in adult critically ill patients supported by a critical analysis of the literature.MethodsGuideline scope andtarget audienceThe scope of this guideline was to provide evidence-based guidance regarding the choice of early resusci-tation fluid in adult critically ill patients due to various etiologies.The target audience for this guideline is front-line clinicians(medical and nursing),allied healthcare workers and policymakers in both high-and low-to-mid-dle-income contexts.Panel selection andorganizationPanel members were appointed with consideration of diversity and inclusivity as previously described 4.The panel consisted of two ESICM Guidelines Co-chairs,one Clinical Chair,two Methods Co-Chairs from ESICM and Guidelines in Intensive Care,Development and Evalua-tion (GUIDE)group,the Chairperson of the Methodol-ogy Group of ESICM,and 11 experts,including clinicians specialized in critical care,anesthesia,infectious diseases and emergency medicine as well as critical care nursing.The roles of the panel members are outlined in the online electronic supplementary material(ESM).Conflict ofinterest managementWe applied the principles of management of conflict of interest(COI)as previously described 5.Panelists were requested to declare any intellectual or financial COI that may influence their participation in the guideline by com-pleting a special form per the ESICM procedures.A sum-mary of individual declarations is provided at the end of the document under the COI section.Panelists received no financial incentives for their participation.In addition,no funding or input from the industry was incorporated into the guideline.Development ofquestions andoutcomes selectionThis guideline addressed the use of commonly used resuscitation fluids in adult critically ill patients:crys-talloids(isotonic saline and balanced crystalloids)and albumin.One question addressed small-volume hyper-tonic or isotonic crystalloids.This guideline did not address other colloids,such as hydroxyethyl starch(HES)or gelatin.In addition,these guidelines did not address fluid choice for managing burns,the use of hypertonic solutions for the management of increased intracranial pressure or the use of albumin solutions to increase serum albumin levels 6,7.At the beginning of the process of the guideline development,the panel proposed several questions according to the Population,Intervention,Comparison,Takehome message For volume expansion,the guideline provides conditional recommendations for using crystalloids rather than albumin in critically ill patients in general,in patients with sepsis,in patients with acute respiratory failure and in patients in the perioperative period and patients at risk for bleeding.There are conditional recommendations for using isotonic saline rather than albumin in patients with traumatic brain injury and for using albumin rather than crystalloids in patients with cirrhosis.The guideline provides conditional recommendations for using balanced crystalloids rather than isotonic saline in critically ill patients in general,in patients with sepsis and in patients with kidney injury.There are conditional recommendations for using isotonic saline rather than balanced crystalloids in patients with traumatic brain injury and for using isotonic crystalloids rather than smallvolume hypertonic crystalloids in critically ill patients in general.and Outcomes(PICO)format.After deliberations,the panel prioritized eleven questions,which were approved by the guideline leadership.These questions included the following areas:(A)albumin vs.crystal-loids(six questions;in critically ill patients in general,patients with sepsis,patients with acute respiratory failure,patients with traumatic brain injury(TBI),patients in the perioperative period and in patients with bleeding or at risk for bleeding and patients with cirrhosis);(B)balanced crystalloids vs.isotonic saline(four questions;in critically ill patients in general,patients with sepsis,patients with TBI,and patients with acute kidney injury);(C)one question for small-volume hypertonic vs.isotonic crystalloids.Panelists selected and prioritized outcomes for each PICO on a scale from 1 to 9(ranging from unimpor-tant to critical)8.The following outcomes judged as being critical were included:short-term mortality,need for renal replacement therapy,ventilator-free days/duration of mechanical ventilation,intensive care unit(ICU)-free days/ICU length of stay,hospital-free days/hospital length of stay,quality of life and functional outcomes.For the questions regarding patients with TBI,the additional critical outcome of the extended Glasgow Outcome Scale(GOSE)was used.Literature searchMethodologists searched for relevant systematic reviews and meta-analyses and updated them when needed.When neither was available,we searched for randomized controlled trials in MEDLINE&EMBASE from inception to April 2022,and any relevant trials published subsequently were also included.We used and updated the search,as relevant,from the reviews by Lewis etal.,Tseng etal.and Bai etal.for the ques-tions related to albumin vs.crystalloids 911,by Hammond etal.,Zampieri etal.and Wan etal.for the questions related to balanced crystalloids vs.isotonic saline 1214 and by Orbegozo etal.for small-volume hypertonic vs.isotonic crystalloids 15.Although not included in the grading process,data from observa-tional studies were deliberated in panel meetings,as applicable.Data analysisThe DerSimonian and Laird random-effects model was used when pooling results of effect sizes across rand-omized controlled trials(RCTs)16,17.Relative risks(RRs)with corresponding 95%confidence intervals(CIs)were used for binary outcomes,while mean dif-ferences(MDs)and 95%CIs were used for continu-ous outcomes.The I2 statistic was usedfor descriptive and not inferential purposes,and heterogeneity was assessed mainly on a clinical basis.All analyses were performed using Review Manager(RevMan)Version 5.4,The Cochrane Collaboration,2020 18.Updated RevMan data from Lewis etalwereused 9.In addi-tion,published results from Bayesian meta-analysis or individual patient data meta-analysis were also included when evaluating the evidence.The results of systematic reviews were reported according to the Grading of Rec-ommendations Assessment,Development,and Evalua-tion(GRADE)guidance,considering the size of effect and certainty of evidence 19.Risk ofbias andcertainty ofevidenceThe Cochrane Collaboration Risk of Bias(ROB)1.0 tool was used to assess the risk of bias of individual RCTs.The GRADE methodology was applied to evaluate the certainty of evidence 20.Accordingly,the certainty of evidence from randomized controlled trials for each critical outcome started with a high rating,but it could be downgraded by one or two points for each of the fol-lowing domains:risk of bias,inconsistency,indirectness,imprecision,and publication bias 21.If the evidence was primarily based on study subgroups,the validity of the findings was deliberated during the panel discus-sions.The certainty of evidence for each recommenda-tion was determined considering the totality of evidence across all outcomes including the critical outcome with the lowest certainty 22.In addition and in line with the GRADE methodology,the panel also considered the rela-tive importance of each outcome so that the whole body of evidence is not downgraded based on the lower confi-dence in estimates of the effects of a less critical outcome.For each PICO,we reported the level of certainty for each outcome,the level of certainty for the whole body of evi-dence and the domains that were involved in downgrad-ing in the corresponding Summary of Evidence section,and provided a more detailed description in the Evidence Profile tables in the ESM.The GRADEpro GDT(GRA-DEpro Guideline Development Tool Software,McMas-ter University and Evidence Prime,2022.Available from www.grade pro.org)was used to create evidence profiles for each PICO.Recommendation formulationThe panel met online monthly and used the Evidence-to-Decision(EtD)Framework to formulate recommen-dations 23.As described in the GRADE methodology,the panel considered the following factors:magnitude of effect,certainty of evidence,patient values and pref-erences,resources and cost,equity,acceptability,and feasibility when deciding the direction and strength of recommendations.A strong recommendation in favor of an intervention(reported as“we recommend”)implies that the desirable benefit of the intervention outweighs undesirable effects,that most patients and clinicians would choose the recommendation,and that it can be adopted as a policy.On the other hand,a conditional rec-ommendation in favor of an intervention(reported as“we suggest”)implies that the desirable benefit of the interven-tion outweighs the undesirable effects but with a low con-fidence.It implies that a majority,but not all,individuals will likely be best served by the recommended course of action 23,and that most patients and clinicians,but not all,would accept the suggested action from a conditional recommendation,and for policymakers,it would not be appropriate to be adopted as a policy.To provide practi-cal guidance to critical practitioners,we presented the recommendations in favor of a particular approach rather than against an alternative 24.The panel used consensus to formulate recommendations and all members approved the final recommendations.A family member of a criti-cally ill patient reviewed the recommendations,provided feedback and supported all eleven recommendations.For each PICO,the panel identified unresolved questions and research gaps as relevant.ResultsAlbumin vs.crystalloidsQuestion 1:Should albumin vs.crystalloids be used forvolume expansion inadult critically ill patients ingeneral?RecommendationWe suggest using crystalloids rather than albumin for volume expansion in adult critically ill patients in general.Conditional recommendation,moderate certainty of evidence.RemarkQuestions 2,3,4,5 and 6 address the use of albumin vs.crystalloids in adult critically ill patients with sepsis,adult critically ill patients with acute respiratory failure,adult critically ill patients with TBI,adult critically ill patients in the perioperative period and those with bleeding or at risk for bleeding and adult critically ill patients with cirrhosis,respectively.BackgroundAlbumin has been advocated as a more effective fluid for expanding intravascular volume than crystalloids because it is believed to be more effectively retained within the intravascular space and that itmaintains the intrav