[Association between fluid balance and clinical outcomes in sepsis patients with identified subtypes].

Objective: To identify clinical subphenotypes of sepsis by clinical variables, and the association between fluid balance (FB) and outcomes in sepsis patients with different subphenotypes. Methods: Data were derived from China Critical Care Sepsis Trial. A total of 2 075 patients were included in the study, with a mean age of (62.5±17.4) years, 1 362 (65.6%) were male, 713 (34.3%) were female. In-hospital mortality was the primary outcome. Clinical variables were entered into the latent profile analysis (LPA) model which was used to identify the subphenotypes of sepsis. Multivariable logistic regression model was used to explore the association of FB on the first 2 days admitted to ICU and in-hospital mortality. Results: Total of 687 (33.1%) patients died in the hospital. Four subphenotypes of sepsis were identified by the PLA model: 1 421 (68.5%) patients were identified as profile 1, which was characterized by the lowest in-hospital mortality (28.3%, 402/1 421) and was considered as the baseline subphenotype; profile 2 was characterized by multiple organ dysfunction(232, 11.2%); profile 3 was characterized by respiratory dysfunction (196, 9.4%) and profile 4 was characterized by kidney injury/failure (226, 10.9%). Profile 2 showed the highest in-hospital mortality (54.3%, 126/232), followed by profile 4 (39.4%, 89/226), profile 3 (35.7%, 70/196). Profile 2 had the highest FB of 68.5(34.7, 89.4)ml/kg on day 1 and decreased rapidly to 29.4(13.6, 49.8) ml/kg on day 2. Multivariable analysis showed that for every 10 ml/kg of FB increased on the first 48 hours admitted to ICU, the risk of in-hospital mortality decreased 14% (OR=0.86, 95%CI: 0.81-0.97) in profile 2, and increased 4% (OR=1.04, 95%CI:1.02-1.07) in profile 4. However, there were no significant association between FB on the fist 2 days admitted to ICU and the risk of in-hospital mortality in profile 1 (OR=1.06, 95%CI: 0.94-1.19)and in profile 3 (OR=0.99, 95%CI: 0.94-1.05). Conclusions: Four subphenotypes of sepsis were identified according to the clinical variables, which showed different characteristics, distributions, outcomes and responses to fluid balance.目的： 利用常规临床变量确定脓毒症的表型，进一步探讨液体平衡与脓毒症不同表型预后的关系。 方法： 本研究数据来源于2013年1月到2014年8月中国危重症患者脓毒症调查研究。共2 075例脓毒症患者纳入最终分析，其中男1 362（65.6%）例，女713（34.4%）例，年龄（62.5±17.4）岁。住院病死率为主要临床结局。利用常规临床变量采用潜剖面分析模型确定脓毒症表型。采用多因素logistic回归模型探讨入住重症监护病房（ICU）前2天液体平衡量与不同表型脓毒症患者住院病死率的关系。 结果： 共687（33.1%）例患者住院期间死亡。通过潜剖面分析，将脓毒症确定为4种临床表型。表型1为基础表型共1 421例（68.5%），无明显器官功能衰竭，住院病死率最低，为28.3%（402/1 421）；表型2共232例（11.2%），以多器官功能衰竭为特征；表型3共196例（9.4%），以呼吸功能衰竭为特征；表型4共226（10.9%）例，以肾脏功能受损/衰竭为主。表型2组的住院病死率最高，为54.3%（126/232），其次为表型4（39.4%，89/226）、表型3（35.7%，70/196）。表型2组第1天液体平衡量最多，为68.5（34.7，89.4）ml/kg，第2天迅速降至29.4（13.6，49.8）ml/kg。入ICU前48 h累积液体平衡量每升高10 ml/kg，表型2组患者住院死亡风险降低14%（OR=0.86，95%CI：0.81~0.97）；表型4组患者住院死亡风险增加4%（OR=1.04，95%CI：1.02~1.07）；而表型1组（OR=1.06，95%CI：0.94~1.19）和表型3组（OR=0.99，95%CI：0.94~1.05）前2天液体平衡量与住院死亡风险无相关性。 结论： 根据临床变量可将脓毒症确定为4种临床表型，其特点、分布、结局存在明显差异，且不同临床表型对液体反应也存在差异。.