液体复苏胶体的地位ppt课件.ppt

液体复苏 胶体的地位 170多年前 1832年 一位苏格兰医师 发现了这种通过静脉血管把药液送入人体的治疗手段 为什么要开发出这些胶体 重症液体复苏的重要性胶体及其作用目前的争论总结 什么是胶体 胶体 colloid 又称胶状分散体 colloidaldispersion 是一种均匀混合物 在胶体中含有两种不同相态的物质 一种分散 另一种连续 分散的一部分是由微小的粒子或液滴所组成 大小介于1到100纳米之间 且几乎遍布在整个连续相态中 按分散剂的不同可分为 气溶胶 雾 烟 云 固溶胶 水晶 有色玻璃 液溶胶 蛋白溶液 淀粉溶液 肥皂水 人体血液 人体白蛋白的含量与分布 细胞内液 细胞外液 体液 约占人体体重60 40 组织间液15 血浆5 蛋白质在血浆中含量远远高于组织间液血浆总蛋白含量约为60 80g L其中 白蛋白含量约为35 50g L 占血浆总蛋白的60 Frank Starling定律 Multi OrganFailure Microcirculatorydysfunction Whatelsebesidesvolumerestrictionandexpansion Fluidresuscitation Tissueoxygenation Capillaryleakamelioration Hemodynamics Clinicaloutocme RiskofAnaphylaxis Effectoncoagulation EffectonRenalfunction Jean LouisVincent MaxHarryWeil CritCareMed2006 34 1333 1337 Introduction Acutelyillpatientsfrequentlyrequirefluidrepletion HypovolemiaExternalloss bleeding gastrointestinal urinarytracts skinInternalloss extravasationofblood exudation transudationoffluidsRelativeHypovolemia increasesvenouscapacitanceSepsis drugsVolumerepletionmaybeessentialtorestorecriticallevelsofcardiacoutputandarterialpressure resultinginmorenormalperfusionofvitalorgansandtissues Jean LouisVincent MaxHarryWeil CritCareMed2006 34 1333 1337 AcutelyillpatientsfrequentlyrequirefluidrepletionHypovolemia externalloss internallossRelativeHypovolemia increasesvenouscapacitanceVolumerepletionmaybeessentialRestorecriticallevelsofcardiacoutputandarterialpressureMorenormalperfusionofvitalorgansandtissues Jean LouisVincent MaxHarryWeil CritCareMed2006 34 1333 1337 Introduction Hemorrhage Benefit riskoffluidrepletionmustbeassessedBenefitsofdelayedresuscitationLargevolumeoffluid redcelldeficit oxygendeficitPersistenthypovolemiawillresultinMODS Fluidrepletionistypicallymoreeffectiveduringhypovolemicstatesbutislesseffectiveinlaterstages Jean LouisVincent MaxHarryWeil CritCareMed2006 34 1333 1337 fluidchallenge Jean LouisVincent MaxHarryWeil CritCareMed2006 34 1333 1337 DistinguishedfromconventionalfluidadministrationUsuallytocriticalpatientswithcardiorespiratoryfailureThefluidchallengeisreservedforhemodynamicallyunstablepatientsandoffersthreemajoradvantages Quantitationofthecardiovascularresponseduringvolumeinfusion Promptcorrectionoffluiddeficits Minimizingtheriskoffluidoverloadanditspotentiallyadverseeffects especiallyonthelungs 重症液体复苏的重要性胶体及其作用目前的争论总结 复苏液体种类 高渗盐液7 5 盐水 低右 晶体液复苏 赞成使用晶体液的理由 费用低 容易得到对肾功能保持较好很少产生不良反应 这几种液体都能纠正脱水可纠正低钠血症高渗盐水 HS 扩容效率高反对使用晶体液的理由 平均留驻时间短 只有45min 液体输入量大造成血清白蛋白的稀释 血渗透压降低 间质水肿 肺水肿稀释血中凝血因子降低血小板计数和血红细胞压积血液携氧能力下降 降低组织氧合 KoustovaE StantonK GushchinV etal Trauma2002 52 872 878 RotsteinOD Trauma2000 49 580 83 LangK BoldtJ SuttnerS etal Analg 2001 93 405 409 Theedemaproblemofcrystalloidsiswellknown Fluidispouredintotheinterstitialspaceonclinicalinformationgainedfromchangesinintravascularspace Theendpoint peripheralorpulmonaryedema Twigley40 860 871 因生存率下降NHLBI终止高张盐水治疗休克的研究 NIH所属的国立心肺血液研究所 NHLBI 已经终止了一项有关严重出血导致休克的创伤患者的临床液体复苏干预试验该试验旨在研究高张盐水溶液治疗此类患者疗效及安全性试验终止的原因 观察到高张盐水治疗组患者在到达医院或急诊科前病死率显著升高 尽管高张盐水组及生理盐水组患者28天病死率 研究终点 相似 NHLBIHaltsStudyofConcentratedSalineforShockDuetoLackofSurvivalBenefit AmericanAcademyofEmergencyMedicine2009 16 3 MedScapeToday COPbalanceessentialforbalancedflowacrosscapillary胶体渗透压的平衡是毛细血管的交换的基本因素CrystalloidscannotimpactCOP Edema单独使用晶体无法维持胶体渗透压 水肿 ColloidshelptorestoreCOPandreduceCrystalloidload胶体液有助于恢复胶体渗透压和减少晶体负荷 Artery Arteriole 动脉 小动脉 Vein Venule 静脉 小静脉 PlasmaProteinColloidOsmoticPressure胶体渗透压22mmHg 简化Starling定律 HydrostaticPressure静水压32mmHg HydrostaticPressure静水压12mmHg TissueFluid组织液 HypovolemiaEdema organdamage低血容量水肿 器官损伤 胶体渗透压 胶体液的作用 容量作用 维持血流动力学稳定维持血浆胶体渗透压改善微循环 改善组织细胞氧供非容量作用 改善CLS改善炎性反应物质结合和转运抗氧化作用 colloid 151consecutivelymajortraumapatients WilliamC ShoemakerOutcomePredictionofEmergencyPatientsbyNoninvasiveHemodynamicMonitoringChest 2001 120 528 537 WilliamC ShoemakerOutcomePredictionofEmergencyPatientsbyNoninvasiveHemodynamicMonitoringChest 2001 120 528 537 Hemodynamcs crystalloid 151consecutivelymajortraumapatients Normal SubstanceP 1minlater StudyofCapillaryLeak Direct ScanningEM normalendothelialcelljunctionDonaldMcDonald1999 CritCareMed2006 34 1775 1782 白蛋白增加血浆中抗氧化剂硫醇含量 GregoryJ etc CritCareMed 2004 32 755 759 白蛋白增加血浆中抗氧化剂含量 GregoryJ etc CritCareMed 2004 32 755 759 TheSAFEStudy Alb salinedeaths726 729 RR0 99 SimilarneworganfailuresICULOSHospitalLOSVentilatordurationRRTConclusion OutcomewithalbumininICUnodifferentfromSaline Q Doesthismeancrystalloidsandcolloidsarethesame Doesthismeanallcolloidsaresame Finferetal NEJM2004 350 2247 56 重症液体复苏的重要性胶体及其作用目前的讨论总结 胶体液复苏并无优势 荟萃分析 Objective theeffectonmortalityofresuscitationwithcolloidcomparedwithcrystalloids Design Systematicreviewofrandomisedcontrolledtrialsofresuscitationwithcolloidscomparedwithcrystalloidsforcriticallyillpatients Subjects 37randomisedcontrolledtrialswereeligible 26uncompoundedtrialsthatcomparedcolloidswithcrystalloids n 1622 10trialsthatcomparedcolloidinhypertoniccrystalloidwithisotoniccrystalloid n 1422 andonetrialthatcomparedcolloidinisotoniccrystalloidwithhypertoniccrystalloid n 38 SchierhoutG RobertsI Fluidresuscitationwithcolloidorcrystalloidsolutionsincriticallyillpatients asystematicreviewofrandomisedtrials BMJ1998 316 961 4 Conclusions Thissystematicreviewdoesnotsupportthecontinueduseofcolloidsforvolumereplacementincriticallyillpatients CochraneReport 2008 ObjectivesToassesstheeffectsofcolloidscomparedtocrystalloidsforfluidresuscitationincriticallyillpatients Mainresults identified63eligibletrials 55ofthesepresentedmortalitydata Colloidscomparedtocrystalloids Albumin 23trialsreporteddataonmortality includingatotalof7 754patients Thepooledrelativerisk RR was1 01 95 confidenceinterval 95 CI 0 92to1 10 Whenthetrialwithpoorqualityallocationconcealmentwasexcluded pooledRRwas1 00 95 CI0 91to1 09 Hydroxyethylstarch 16trialscomparedhydroxyethylstarchwithcrystalloids n 637patients ThepooledRRwas1 05 95 CI0 63to1 75 Modifiedgelatin 11trialscomparedmodifiedgelatinwithcrystalloid n 506patients ThepooledRRwas0 91 95 CI0 49to1 72 Dextran ninetrialscompareddextranwithacrystalloid n 834patients ThepooledRRwas1 24 95 CI0 94to1 65 Eighttrialscompareddextraninhypertoniccrystalloidwithisotoniccrystalloid including1 283randomisedparticipants PooledRRwas0 88 95 CI0 74to1 05 PerelP RobertsI Colloidsversuscrystalloidsforfluidresuscitationincriticallyillpatients Review TheCochraneLibrary2008 Issue3 Authors conclusions ThereisnoevidencefromRCTsthatresuscitationwithcolloidsreducestheriskofdeath comparedtoresuscitationwithcrystalloids inpatientswithtrauma burnsorfollowingsurgery CochraneReport 2008 Ascolloidsarenotassociatedwithanimprovementinsurvival andastheyaremoreexpensivethancrystalloids itishardtoseehowtheircontinueduseinthesepatientscanbejustifiedoutsidethecontextofRCTs PerelP RobertsI Colloidsversuscrystalloidsforfluidresuscitationincriticallyillpatients Review TheCochraneLibrary2008 Issue3 注 Cochrane是国际最大的循证医学试验的协作网 以已故英国内科医师和著名流行病学家ArchieCochrane的名字命名 胶体 ICU用 还是不用 FluidChallenge 500 100mlcristalloids300 500mlcolloidsover30mincontrolCVPorPAOPandreducespeed volumeaccordingly Grade1D SurvivingSepsisCampaign Internationalguidelinesformanagementofseveresepsisandsepticshock 2008CritCareMed2008Vol 36 No 1 Figure Differences inpercentagefrombaseline oftissueoxygentension ptio2 inthetwovolumegroups KatrinLang JoachimBoldt StefanSuttner etal ColloidsVersusCrystalloidsandTissueOxygenTensioninPatientsUndergoingMajorAbdominalSurgery AnesthAnalg2001 93 405 9 白蛋白对于重症患者 结论 白蛋白可以显著降低重症病例整体并发症的发生 危险比 0 92 可信区间 0 86 0 98 且并发症的发生率与白蛋白的使用剂量显著相关 p 0 002 Albumin B 004 Vincent Jean Louis Navickis RobertaJ Wilkes MahlonM Morbidityinhospitalizedpatientsreceivinghumanalbumin Ameta analysisofrandomized controlledtrials CritCareMed2004 32 10 2029 2038 胶体 我们关心的组织氧代谢 SHOCK 2006Vol 25 No 2 pp 103Y116 SchortgenetcollLancet2001 357 911 Survivors HEAorgelatineforSevereSepsis Resuscitation selectionofFluid CrystalloidsorColloidscanbeusedFluidchallengeswithcolloidsallowformorerapidcompletionofchallenge Crystalloid Physiologic 0 9 saltsolution saline MayincreaseserumchlorideconcentrationsBalancedsaltsolutions Ringer slactate Hartmann ssolution Mildlyhypotonic mayexacerbatecerebraledema Jean LouisVincent MaxHarryWeil CritCareMed2006 34 1333 1337 Resuscitation selectionofFluid SAFEstudy albuminvscrystalloidsolutionMortalityratewasidenticalHypoalbuminemiaisassociatedwithhighermorbidityVincentJLetal AnnSurg2003 237 319 334 meta analysisAlbuminadministrationmayreducecomplicationsincriticallyillpatientsSAFEtrial Improvedsurvivalwithalbumininpatientswithsepsiswhoarehypoalbuminemia relativeriskofdeath 0 87 95 C