Sepsis患者的液体管理.ppt

Sepsis患者的液体管理,患者，男，39岁。主诉：右下腹痛伴发热3天,加重1天。8月14日入急诊室，8月15日1405入院。,Case,腹痛待查局限性腹膜炎急性阑尾炎,入普外科时诊断,感染性休克急性坏疽性阑尾炎阑尾周围脓肿阑尾切除术后ARDSI型呼吸衰竭,入ICU诊断,8.15术中进量1000ml,出血20mlDATEINOUTBalanceTmax8.1644501800+265036.88.1716104490-188037.38.1812502450-120037.58.1918602740-88037.3,FluidBalance,ARDS(急性呼吸窘迫综合征),静脉输液的历史,ThediscoveryofthecirculationofthebloodbyWilliamHarveyin1628formedthebasisfortherationaleforIVinjectionsandinfusions,输液目的,普通静脉输液（按要求稀释药物）容量复苏Volumeresuscitation(液体复苏Fluidresuscitation)（补充患者体内不足）,FluidisadrugthatcanbeoverdosedintheICU,S.LGoldsteinDepartmentofNephrologyandHypertensionCincinnatiChildrensHospitalMedicalCenter,USA,如何实施液体管理？,没有明确答案,在中国,IntheICU:重症患者Inthewards:前重症患者or重症患者,PatientswithSIRS,毛细血管渗漏综合征（CapillaryLeakSyndrome，CLS）,定义毛细血管内皮细胞损伤，血管通透性增高，造成间质水肿（如肺泡水肿，气体交换受限），组织缺氧又加重毛细血管内皮细胞损伤，形成恶性循环，引起器官功能障碍病因严重创伤、Sepsis、ARDS、烧伤、体外循环手术、再灌注损伤等。主要表现一般：全身水肿，血液浓缩，低蛋白血症器官：肺，肝，脑,各种情况下的水的分布,内毒素血症-高容量组,高容量复苏与死亡率：动物实验,内毒素血症-中等容量组,腹膜炎-高容量组,腹膜炎-中等容量组,结论高容量复苏增加脓毒症的死亡率。液体管理策略影响脓毒症的预后。,生存率,大量研究表明：液体过多与预后不佳有关,1.SimmonsRS,BerdineGG,SeidenfeldJJ,etal:Fluidbalanceandtheadultrespiratorydistresssyndrome.AmRevRespirDis1987;135:9249292.HumphreyH,HallJ,SznajderI,etal:ImprovedsurvivalinARDSpatientsassociatedwithareductioninpulmonarycapillarywedgepressure.Chest1990;97:117611803.SchullerD,MitchellJP,CalandrinoFS,etal:Fluidbalanceduringpulmonaryedema.Isfluidgainamarkeroracauseofpooroutcome?Chest1991;100:106810754.AlsousF,KhamieesM,DeGirolamoA,etal:Negativefluidbalancepredictssurvivalinpatientswithsepticshock:Aretrospectivepilotstudy.Chest2000;117:17491754,大量研究表明：液体过多与预后不佳有关,5.RiversE,NguyenB,HavstadS,etal:EarlyGoal-DirectedTherapyCollaborativeGroup:Earlygoal-directedtherapyinthetreatmentofseveresepsisandsepticshock.NEnglJMed2019;345:136813776.SakrY,VincentJL,ReinhartK,etal;SepsisOccurenceinAcutelyIllPatientsInvestigators:Hightidalvolumeandpositivefluidbalanceareassociatedwithworseoutcomeinacutelunginjury.Chest2019;128:309831087.VincentJL,SakrY,SprungCL,etal:SepsisOccurrenceinAcutelyIllPatientsInvestigators:SepsisinEuropeanintensivecareunits:ResultsoftheSOAPstudy.CritCareMed2019;34:3443538.RosenbergAL,DechertRE,ParkPK,etal:NIHNHLBIARDSNetwork:Reviewofalargeclinicalseries:Associationofcumulativefluidbalanceonoutcomeinacutelunginjury:AretrospectivereviewoftheARDSnettidalvolumestudycohort.JIntensiveCareMed2009;24:3546,大量研究表明：液体过多与预后不佳有关,9.RosenbergAL,DechertRE,ParkPK,etal;NIHNHLBIARDSNetwork:Reviewofalargeclinicalseries:Associationofcumulativefluidbalanceonoutcomeinacutelunginjury:AretrospectivereviewoftheARDSnettidalvolumestudycohort.JIntensiveCareMed2009;24:354610.StewartRM,ParkPK,HuntJP,etal;NationalInstitutesofHealth/NationalHeart,Lung,andBloodInstituteAcuteRespiratoryDistressSyndromeClinicalTrialsNetwork:Lessismore:Improvedoutcomesinsurgicalpatientswithconservativefluidadministrationandcentralvenouscathetermonitoring.JAmCollSurg2009;208:72573511.BoydJH,ForbesJ,NakadaTA,etal:Fluidresuscitationinsepticshock:Apositivefluidbalanceandelevatedcentralvenouspressureareassociatedwithincreasedmortality.CritCareMed2019;39:25926512.TheRENALReplacementTherapyStudyInvestigators:Anobservationalstudyoffluidbalanceandpatientoutcomesintherandomizedevaluationofnormalvs.augmentedlevelofreplacementtherapytrial.CritCareMed2019;40:17531760,静态评估,动态评估,两种序贯容量管理策略,Adequateinitialfluidresuscitation(AIFR)早期恰当容量复苏administrationofaninitialfluidbolusof20mL/kgpriortotovasopressortherapyinitiationandachievementofacentralvenouspressureof8mmHgwithin6haftertheonsetoftherapywithvasopressorsConservativelatefluidmanagement(CLFM)后期限制性液体管理even-to-negativefluidbalancemeasuredonatleast2consecutivedaysduringthefirst7daysaftersepticshockonset,何谓“限制性容量管理”（conservativeorrestrictedfluidmanagement）,维持每日液体进出量基本或(尽可能)负平衡Dailyeven-to-negativefluidbalance满足细胞、组织适当的灌注为细胞、组织提供足够的氧气、足够的营养维持重要器官功能,Fluidmaybeafriendwhenappropriatelytitratedduringtheresuscitation,orebb,phaseofacutelunginjur