Background

Fluid therapy—the administration of fluids to maintain adequate organ tissue perfusion and oxygenation—is essential in patients admitted to the intensive care unit (ICU) with traumatic brain injury. We aimed to quantify the variability in fluid management policies in patients with traumatic brain injury and to study the effect of this variability on patients' outcomes.

Methods

We did a prospective, multicentre, comparative effectiveness study of two observational cohorts: CENTER-TBI in Europe and OzENTER-TBI in Australia. Patients from 55 hospitals in 18 countries, aged 16 years or older with traumatic brain injury requiring a head CT, and admitted to the ICU were included in this analysis. We extracted data on demographics, injury, and clinical and treatment characteristics, and calculated the mean daily fluid balance (difference between fluid input and loss) and mean daily fluid input during ICU stay per patient. We analysed the association of fluid balance and input with ICU mortality and functional outcome at 6 months, measured by the Glasgow Outcome Scale Extended (GOSE). Patient-level analyses relied on adjustment for key characteristics per patient, whereas centre-level analyses used the centre as the instrumental variable.

Findings

2125 patients enrolled in CENTER-TBI and OzENTER-TBI between Dec 19, 2014, and Dec 17, 2017, were eligible for inclusion in this analysis. The median age was 50 years (IQR 31 to 66) and 1566 (74%) of patients were male. The median of the mean daily fluid input ranged from 1·48 L (IQR 1·12 to 2·09) to 4·23 L (3·78 to 4·94) across centres. The median of the mean daily fluid balance ranged from −0·85 L (IQR −1·51 to −0·49) to 1·13 L (0·99 to 1·37) across centres. In patient-level analyses, a mean positive daily fluid balance was associated with higher ICU mortality (odds ratio [OR] 1·10 [95% CI 1·07 to 1·12] per 0·1 L increase) and worse functional outcome (1·04 [1·02 to 1·05] per 0·1 L increase); higher mean daily fluid input was also associated with higher ICU mortality (1·05 [1·03 to 1·06] per 0·1 L increase) and worse functional outcome (1·04 [1·03 to 1·04] per 1-point decrease of the GOSE per 0·1 L increase). Centre-level analyses showed similar associations of higher fluid balance with ICU mortality (OR 1·17 [95% CI 1·05 to 1·29]) and worse functional outcome (1·07 [1·02 to 1·13]), but higher fluid input was not associated with ICU mortality (OR 0·95 [0·90 to 1·00]) or worse functional outcome (1·01 [0·98 to 1·03]).

Interpretation

In critically ill patients with traumatic brain injury, there is significant variability in fluid management, with more positive fluid balances being associated with worse outcomes. These results, when added to previous evidence, suggest that aiming for neutral fluid balances, indicating a state of normovolaemia, contributes to improved outcome.

Funding

European Commission 7th Framework program and the Australian Health and Medical Research Council.

中文翻译：

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创伤性脑损伤危重患者（CENTER-TBI 和 OzENTER-TBI）的体液平衡和结果：一项前瞻性、多中心、比较有效性研究

背景

液体疗法——给予液体以维持足够的器官组织灌注和氧合——对于因创伤性脑损伤入住重症监护病房 (ICU) 的患者至关重要。我们旨在量化创伤性脑损伤患者液体管理政策的变异性，并研究这种变异性对患者预后的影响。

方法

我们对两个观察性队列进行了前瞻性、多中心、有效性比较研究：欧洲的 CENTER-TBI 和澳大利亚的 OzENTER-TBI。该分析包括来自 18 个国家的 55 家医院、年龄在 16 岁或以上的需要头部 CT 的颅脑外伤患者并入住 ICU 的患者。我们提取了人口统计学、损伤、临床和治疗特征的数据，并计算了每位患者在 ICU 住院期间的平均每日液体平衡（液体输入和流失之间的差异）和平均每日液体输入。我们分析了液体平衡和输入与 6 个月时 ICU 死亡率和功能结果的关联，通过格拉斯哥结局量表扩展 (GOSE) 测量。患者层面的分析依赖于对每位患者关键特征的调整，

调查结果

2014 年 12 月 19 日至 2017 年 12 月 17 日期间参加 CENTER-TBI 和 OzENTER-TBI 的 2125 名患者符合纳入本分析的条件。中位年龄为 50 岁（IQR 31 至 66），1566 名（74%）患者为男性。各中心平均每日液体输入的中位数范围为 1·48 升（IQR 1·12 至 2·09）至 4·23 升（3·78 至 4·94）。各中心平均每日液体平衡的中位数范围为 -0·85 L（IQR -1·51 至 -0·49）至 1·13 L（0·99 至 1·37）。在患者水平分析中，平均每日液体正平衡与较高的 ICU 死亡率（每增加 0·1 L 的比值比 [OR] 1·10 [95% CI 1·07 至 1·12]）和较差的功能结果相关（1·04 [1·02 至 1·05] 每 0·1 升）；较高的平均每日液体输入量也与较高的 ICU 死亡率（每增加 0·1 L 1·05 [1·03 至 1·06]）和较差的功能结果（每增加 1·04 [1·03 至 1·04]每增加 0·1 L，GOSE 减少 1 点）。中心级分析显示，较高的液体平衡与 ICU 死亡率（OR 1·17 [95% CI 1·05 至 1·29]）和较差的功能结果（1·07 [1·02 至 1·13]）之间存在相似的关联，但较高的输液量与 ICU 死亡率（OR 0·95 [0·90 至 1·00]）或更差的功能结果（1·01 [0·98 至 1·03]）无关。

口译

在患有创伤性脑损伤的危重患者中，液体管理存在显着差异，液体平衡越多，结果越差。这些结果与之前的证据相结合，表明以中性体液平衡为目标，表明血容量正常，有助于改善结果。

资金

欧盟委员会第七框架计划和澳大利亚健康与医学研究委员会。