| Objective:To evaluate the effect of different crystalloids resuscitation on renal function and internal environment during the early stage of septic shock in patients.Methods:From June 2016 to January 2017,a total of 140 patients with septic shock admitted to the Intensive Care Unit(ICU)of Northern Jiangsu People’s Hospital were enrolled.All eligible patients were randomly divided into 0.9%a sodium chloride solution group(group N,n=47),Ringer’s solution group(group L,n=47)and acetate sodium potassium magnesium calcium glucose solution group(group P,n=46).In all patients,catheters were placed in the right internal jugular vein or subclavian vein and were infused with the corresponding crystalloid.In the first three hours of determining a diagnosis of septic shock,30 mL/kg of crystalloid solution was administered.Within six hours,the application of vasopressors was determined by the researcher;according to fluid responsiveness,the rehydration rate and fluid volume were also determined by the investigator.In this study,6-hour or 24-hour fluid volume,antibiotic therapy within the first hour,vasopressors,and exogenous insulin application were recorded.The levels of arterial blood pH,base excess(BE),lactic acid(Lac),chloride,calcium,sodium,potassium,blood glucose,plasma neutrophil gelatinase-associated lipocaliin(pNGAL),urinary neutrophil gelatinase-associated lipocaliin(uNGAL),urine volume,mean artery pressure,and so on were also recorded at 0,3,6,and 24 hours and at 3 and 7 days.The primary outcome was the proportion of patients with acute kidney injury(AKI),and the secondary outcomes were incidence of renal replacement therapy(RRT),28-day mortality,ICU mortality,length of ICU or hospital stay,and days on mechanical ventilation.Results:1.Liquid volume,norepinephrine application,and MAPGroups N,L,and P had similar characteristics,such as 6-hour fluid volume[3250(2670-3665)mL,3160(2400-3960)mL,3275(2680-4031)mL,p>0.05],24-hour fluid volume[6252(5087-8709)mL,5770(4386-7857)mL,6902(5021-8262)mL,p>0.05],6-hour colloid volume[100(100-200)mL,110(100-200)mL,100(100-200)mL,p>0.05],24-hour colloid volume[200(100-400)mL,300(200-300)mL,260(200-400)mL,p>0.05],norepinephrine duration[3(1-4)days,2(1-3)days,3(2-4.25)days,p>0.05],maximum norepinephrine quantity[0.5(0.4-1.3)μg/kg-1·min-1 0.5(0.2-1.0)μg/kg-1·min-1,0.5(0.2-0.8)μg/kg-1·min-1,p>0.05].In addition,there were no significant differences in MAP among groups N,L,and P at each time point before and after fluid resuscitation(p>0.05).2.Arterial blood gas,acid-base,electrolyte,and blood glucoseThere were no significant differences in arterial blood pH(7.33±0.11,7.34±0.11,7.33±0.10,p>0.05),BE(-6.43±5.05,-3.48±7.03,-6.08±7.01,p>0.05),Lac(3.40±1.88 mmol/L,3.80±2.83 mmol/L,3.77±2.59 mmol/L,p>0.05),chloride(105.8±7.53 mmol/L,102.6±6.62 mmol/L,103.9±6.40 mmol/L,p>0.05),calcium(1.10±0.11 mmol/L,1.11±0.10 mmol/L,1.13±0.08 mmol/L,p>0.05),sodium(142.2±6.12 mmol/L,140.7±6.16 mmol/L,140.9±7.74 mmol/L,p>0.05),potassium(4.02±0.96 mmol/L,3.69±0.59 mmol/L,3.73±0.82 mmol/L,p>0.05),blood glucose(8.77±4.]2 mmol/L,9.61 ±5.17 mmol/L,8.32±3.28 mmol/L,p>0.05)among groups N,L,and P,respectively,at 0 hours.Moreover,arterial blood pH,BE,Lac,sodium,potassium,and blood glucose in the three groups were not different at other time points after fluid resuscitation(p>0.05).Chloride plasma concentration in group N(108.5±6.64 mmol/L)was significantly higher than in groups L(106.3±4.80 mmol/L)and P(105.1 ±4.26 mmol/L)at 24 hours(p<0.05),with no significant differences between groups L and P(p>0.05).In addition,chlorine plasma concentration in the three groups were not significantly different at other time points(p>0.05).At three hours,calcium plasma concentration in group N(1.08±0.09 mmol/L)was significantly lower than in groups L(1.15±0.09 mmol/L)and P(1.12±0.10 mmol/L)(p<0.05),with no significant differences between groups L and P(p>0.05).At six hours,the calcium plasma concentration in group N(1.12±0.10 mmol/L)was significantly lower than that in groups L(1.16±0.08 mmol/L)and P(1.15±0.08 mmol/L)(p<0.05),with no significant differences between groups L and P(p>0.05).However,calcium plasma concentration among the three groups was not significantly different at other time points(p>0.05).3.Antibiotic therapy within the first hour and exogenous insulinThere were no significant differences in antibiotic therapy within the first hour(66.0%,66.0%,69.6%,p>0.05)among groups N,L,and P,respectively.Insulin accumulation within seven days was higher in group P[3.5(0-38.5)IU]than in groups N[0(0-32)IU]and L[0(0-81)IU],but with no statistically significant differences among the three groups(p>0.05).4.Renal function and biological markersThere were no significant differences in urine volume among group N,L and P at each time point before and after fluid resuscitation(p>0.05).Serum creatinine(136.3±52.2μmol/L,125.1 ±22.2 μmol/L,128.5± 19.3 μmol/L,p>0.05)was not significantly different among groups N,L,and P at zero hours.Serum creatinine in group L increased at three hours and then decreased at six hours,rose again at 24 hours,and peaked at seven days.Serum creatinine in groups N and P did not fluctuate significantly after fluid resuscitation.Moreover,serum creatinine in the three groups was not significantly different at other time points(p>0.05).In addition,pNGAL(6.02±1.72 μg/L,6.09±0.95 μg/L,5.97±0.99 μg/L,p>0.05)was not significantly different among groups N,L,and P at zero hours.pNGAL in group P decreased at three hours,rose at six hours,peaked at 24 hours,and then decreased again.Moreover,pNGAL in the three groups was significantly different at other time points(p>0.05).In addition,there was no significant difference in uNGAL(5.57± 1.41 μg/L,5.63± 1.00 μg/L,6.06± 1.34 pg/L,p>0.05)among groups N,L,and P at zero hours.Resuscitation uNGAL in groups N and L began to rise at three hours,uNGAL in group N peaked at six hours,and uNGAL in group L peaked at seven days.uNGAL in group P began to decline at three hours and reached its nadir at six hours.At six hours,uNGAL in group N(5.97±1.30 μgg/L)was significantly higher than in groups L(5.79±0.90 μg/L)and P(5.36±1.25 μg/L)(p<0.05),with no significant differences between group L and P(p>0.05).uNGAL in the three groups were not significantly different at other time points(p>0.05).5.Clinical outcomeThe incidence of AKI in group N(66.0%)was higher than in groups L(63.8%)and P(56.5%);however,no statistically significant differences among the three groups were found(p>0.05).Renal-replacement therapy(38.3%,23.4%,21.7%,p>0.05)was similarly used in group N,L,and P.There were no significant differences in 28-day mortality(42.6%,40.4%,41.3%,p>0.05)or ICU mortality(40.4%,34.0%,28.3%,p>0.05)among group N,L,and P,nor was the length of ICU stay[5(3-10)days,5(3-10)days,7(3-20)days,p>0.05]or the length of hospital stay[13(4-20)days,14(3-28)days,13.5(5-28)days,p>0.05],and days on mechanical ventilation[4(2-7)days,3(2-10)days,4(1-10)days,p>0.05].6.Logistic regression analysis of factors influencing 28-day mortality in patients with septic shockThe binary logistic regression model showed that 24-hour pH(OR 0.001,95%CI:0.000-0.093,p=0.004),Lac(OR 1.590,95%CI:1.143-2.211,p=0.006),COPD(OR 9.420,95%CI:2.435-36.306,p=0.001),antibacterial drug application at 1 hour(OR 0.272,95%CI:0.110-0.675,p=0.005),AKI stage 2(OR 6.182,95%CI:1.156-33.071,p=0.033),and AKI stage 3(OR 4.554,95%CI:1.114-18.618,p=0.035)were independent factors that influenced 28-day mortality in patients with septic shock.Conclusion:During the early stage of septic shock in patients receiving crystalloids resuscitation,compared with Ringer’s solution and acetate sodium potassium magnesium calcium glucose solution,0.9%sodium chloride solution may cause early kidney injury.Hyperchloremia may be an important pathogenesis of early kidney injury caused by 0.9%sodium chloride solution.This study was approved by the Human Research Ethics Committee of Northern Jiangsu People’s Hospital(license number:2016037)and was registered in the Chinese Clinical Trial Registry(CHiCTR-IOR-16009176). |
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