【Cochrane简语概要】比较不同补液方法对经口服补液不足者，如埃博拉病毒病患者的疗效

埃博拉病毒（Phys.org）

背景 

很多埃博拉病毒病患者因脱水而死。患者通常会出现剧烈的呕吐和腹泻，丢失的液体仅通过饮水很难得到补充。不经消化道补充液体即通过所谓肠外途径也是可行的，这些途径包括经静脉内、经骨内进入骨髓、经皮下脂肪组织、经腹腔内补液。经静脉内补液是常规方法，但用于埃博拉病毒病患者却可能出现问题，首先对于非常缺水的患者来说，开始静脉补液很困难，此外，感染控制操作也可能会使维持补液变得困难。因此那些照顾埃博拉病毒病患者的医护人员有必要了解其他补液途径的优劣，以决定哪种补液方法最适合他们的病人。

（图片来源于网络）

试验检索 

我们在2014年11月17日检索了比较不同肠外补液途径的临床试验。

试验特征 

文章共纳入涉及885名患者的17项试验。没有一项研究涉及埃博拉病毒感染者。15项试验涉及需要肠外补液或给药的患者，2项试验评估了模拟条件（如训练用人体模特）下的不同方法。很多试验质量较差。

主要结果 

将这些试验结果集合到一起，我们发现骨内和皮下途径穿刺都比静脉内途径更容易且更快，但静脉内途径可以补充更多的液体。目前还没有足够的研究可供比较腹膜内途径与其他方法的优劣。 

结论 

照顾埃博拉病毒病患者的医护人员应当了解补液的替代途径。文章纳入的试验研究质量不是很高，因此基于其结果得出结论时也需谨慎。这些试验结果的荟萃分析表明，如果静脉内补液途径易于建立，应当使用静脉内途径以补充更大量的液体，如果静脉内途径无法建立，骨内和皮下途径则可供选择，优点是穿刺更快。目前针对不同肠外补液途径的试验大多质量较低，而且没有涉及埃博拉病毒病患者，因此还应该进行更多的试验。

结论: 

对于无法经口获得足够液体的患者来说，有很多种不同方法可以实现肠外补液。而由于缺乏GRADE评级为低风险的、有足够把握度的试验支持，肠道外补液途径效果的研究目前证据质量有限。尽管如此，有充分证据可以得到以下结论：如外周静脉途径可顺利建立，将可比其他途径补充更大量的液体；如果不能顺利建立，骨内和皮下途径将是可行的备选途径。皮下途径可能适用于那些不是严重脱水，但是体液不断丢失无法经口服进行补充的患者。

【Cochrane Plain Language Summary】Comparison of the different ways of giving fluids to patients who cannot drink enough, such as patients with Ebola virus disease

Background 

Many patients with Ebola virus disease (EVD) die because they are dehydrated. Patients with EVD often experience severe vomiting and diarrhoea, which causes them to lose fluids that are difficult to replace by drinking alone. It is possible to give fluids in ways that do not involve the digestive tract; this is known as parenteral access. This includes infusing fluids into a vein (intravenously), into bone marrow (intraosseously), into fatty tissue under the skin (subcutaneously) or into the abdominal space (intraperitoneally). Giving fluids intravenously is the usual method, but can be problematic in patients with EVD because starting intravenous fluids can be difficult in very dehydrated patients, and infection control practices may make maintaining the infusion challenging. It is therefore useful if those caring for patients with EVD know the advantages and disadvantages of the other ways to give fluids, so that they can decide which is the most suitable for their patients.

Searches for trials 

We carried out searches for trials comparing different parenteral access methods on 17 November 2014.

Trial characteristics 

We found 17 trials involving 885 participants. None involved patients with EVD. Fifteen trials involved patients who required parenteral access for the infusion of fluids or medicines and two trials assessed different methods under simulated conditions, such as on a training manikin. Many trials were of poor quality.

Key results 

When the results of these trials were gathered together, they suggested that both the intraosseous and subcutaneous routes may be easier and quicker to insert into patients than the intravenous route, but more fluid can be given intravenously than by either the intraosseous or subcutaneous method. There has not been enough research into the intraperitoneal method to know how it compares to the other methods.

Conclusions 

Healthcare workers caring for patients with EVD should be aware of the alternative ways of giving fluids. The trials we found were not of very high quality, therefore we need to be cautious when drawing conclusions based on their results. However, together they suggest if intravenous access can be achieved easily, then this should be used as it allows the infusion of larger volumes of fluid. However, if intravenous access is not possible, intraosseous and subcutaneous routes are alternatives that can be inserted quickly. Many of the trials conducted so far are of poor quality and none involved patients with EVD, therefore more trials should be carried out.

Authors' conclusions: 

There are several different ways of achieving parenteral access in patients who are unable meet their fluid requirements with oral intake alone. The quality of the evidence, as assessed using the GRADE criteria, is somewhat limited because of the lack of adequately powered trials at low risk of bias. However, we believe that there is sufficient evidence to draw the following conclusions: if peripheral intravenous access can be achieved easily, this allows infusion of larger volumes of fluid than other routes; but if this is not possible, the intraosseous and subcutaneous routes are viable alternatives. The subcutaneous route may be suitable for patients who are not severely dehydrated but in whom ongoing fluid losses cannot be met by oral intake.

译者：李文元；审校：梁宁、刘建平、李迅；编辑排版：张晓雯，北京中医药大学循证医学中心

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