休克补液辩论晶体液首选ppt课件

晶体液 VS 胶体液 Crystalloids VS Colloids 1，液体种类的选择 2，复苏策略（量） 3，复苏程度endpoints （度） 液体复苏包括三个主题 Design: Systematic review of randomised controlled trials comparing administration of albumin or plasma protein fraction with no administration or with administration of crystalloid solution in critically ill patients with hypovolaemia, burns, or hypoalbuminaemia. Subjects: 30 randomised controlled trials including1419 randomised patients. Sesults： Pooled difference in the risk of death with albumin was 6% (95% confidence interval 3% to 9%) with a fixed effects model. These data suggest that for every 17 critically ill patients treated with albumin there is one additional death. Conclusions: There is no evidence that albumin administration reduces mortality in critically ill patients with hypovolaemia, burns, or hypoalbuminaemia and a strong suggestion that it may increase mortality. Conclusion: Albumin increase the risk of mortality by 6% Design: Systematic review of randomised controlled trials of resuscitation with colloids compared with crystalloids for volume replacement of critically ill patients. Subjects: 37 randomised controlled trials Type of injury: Trauma, Burns, Surgery, Septic and hypovolaemic shock, ARDS, Vascular leak syndrome 1998-2004 Comments in BMJ SAFESAFE研究研究: : 4% Albumin vs Normal Saline4% Albumin vs Normal Saline （Saline versus Albumin Fluid EvaluationSaline versus Albumin Fluid Evaluation） 双盲随机对照，双盲随机对照，2828天死亡率评估天死亡率评估 澳大利亚新西兰澳大利亚新西兰1616个个ICUICU，共，共69976997个病人个病人 N Engl J Med 2004;350(22):2247-2256 (n=3497) (n=3500) 28天病死率 不同病人群体亚组分析 Albumin NS RR ( 95% CI ) p 创伤 (N=1186) 13.6 10.0 1.36 (0.99-1.86) 0.06 伴颅脑伤 24.5 15.1 1.62 (1.12-2.34) 0.01 (N=492) 不伴颅脑伤 6.2 6.2 1.00 (0.56-1.79) 1.00 (N=694) Trauma 亚组分析 VISEP StudyVISEP Study (HES vs (HES vs Ringers lactate)Ringers lactate) Efficacy of Volume Substitution and Insulin Therapy in Severe Sepsis VISEP Study (VISEP Study (HES vs HES vs Ringers lactateRingers lactate ) ) Subjects： Patients were deemed to be eligible if the onset of the syndrome was less than 24 hours before admission to the ICU or less than 12 hours after admission if the condition developed in the ICU. HES group： HES until a limit of 20 mL/kg/day, then preferentially Ringers or other non-colloid fluids RL group：Ringers lactate VISEP Study (VISEP Study (HES vs HES vs Ringers lactateRingers lactate ) ) VISEP Study (VISEP Study (HES vs HES vs Ringers lactateRingers lactate ) ) VISEP Study (VISEP Study (HES vs HES vs Ringers lactateRingers lactate ) ) P=0.007 between HES doses P=0.345 between Ringers lactate doses VISEP Study (VISEP Study (HES vs HES vs Ringers lactateRingers lactate ) ) VISEP Study (VISEP Study (HES vs HES vs Ringers lactateRingers lactate ) ) The need for renal-replacement therapy and 90-day mortality were significantly correlated with the cumulative dose of HES (P 22 ml/kg BW/day *HES 22 ml/kg BW/day * n=162n=162n=99n=99 p=0.071p=0.071 P0.001P0.001 * on at least one study day VISEP Study (VISEP Study (HES vs HES vs Ringers lactateRingers lactate ) ) VISEP Study (VISEP Study (HES vs HES vs Ringers lactateRingers lactate ) ) VISEP Study (VISEP Study (HES vs HES vs Ringers lactateRingers lactate ) ) 33.6%33.6% 30.9%30.9% 0%0% 25%25% 50%50% 75%75% 24.2%24.2% 22.8%22.8% 0%0% 25%25% 50%50% 75%75% 28-day 28-day 死亡率死亡率 90-day 90-day 死亡率死亡率 死亡率死亡率 (%) (%) n=256n=256n=162n=162 HESHESRingers lactateRingers lactate n=256n=256n=162n=162 p=0.747p=0.747p=0.562p=0.562 VISEP VISEP 研究研究 (HES vs. (HES vs. 乳酸林格氏液乳酸林格氏液 ) ) - - 死亡率死亡率 HES HES 22 ml/kg/BW vs 22 ml/kg/BW vs 乳酸林格氏液乳酸林格氏液 - - VISEP VISEP 研究研究 (HES vs. (HES vs. 乳酸林格氏液）乳酸林格氏液） - - 发病率：发病率： 乳酸林格氏液乳酸林格氏液 vs. HES vs. HES 22 ml/kg BW/ 22 ml/kg BW/天天 - - 胶体液应用的副作用有不少报道，不同 的胶体液副作用不一，白蛋白相对好些 （Vincent JL. Relevance of albumin in modern critical care medicine. Best Pract Res Clin Anaesthesiol 2009; 23:183191，这篇文章强调白蛋白不应 该用于容量复苏） 右旋糖苷（Dextrans）副作用：肾损害 、影响凝血功能、过敏反应 明胶（Gelatin）：对肾功能和凝血功能 影响相对小，但是过敏反应发生率在合 成胶体液中是最高的，同时由于肾滤过 快半衰期短，容量复苏效果较差 HES贺斯溶液（羟乙基淀粉）：影响血 小板功能，减少循环八因子，有导致出 血风险。 新型贺斯溶液（HES130/0.4， tetrastarch）：安全性和副作用还有争 议，目前有一个大型的多中心的随机对 照研究，专门评估HES130/0.4 对严重 脓毒症病人的安全性（CRYSTMAS study） 晶体液组织水肿 晶体液组织水肿 In our study, patients who were resuscitated with albumin received less fluid than those who were resuscitated with saline. During the first four days，the ratio of albumin administered to saline administered was approximately 1:1.4. However, there was no significant difference in mean arterial pressure between the groups, and the differences in central venous pressure and heart rate were small. Thus, we believe that the patients in the two groups were resuscitated to similar