麻醉专业培训-休克与液体治疗

休克与液体治疗液体复苏的历史液体复苏的历史，1492年教皇

输血后死亡1831年,WilliamOShaughnessy

报导霍乱病人有严重的脱水，建议静脉注射加盐的热水

“theinjectionintotheveinsoftepidwaterholdingasolutionofnormalsaltsoftheblood.”同年ThomasLatta

成功的给霍乱病人静脉注射了盐水和碳酸氢钠液体复苏的历史1891年开始使用盐水治疗休克WorldWarII静脉输液治疗失血性休克取得明显疗效.美军在战争期间采购了400万瓶静脉输液

KoreanWar中静脉输液治疗休克得到进一步改善Improvementinresuscitationandthechangingepidemiologyoftraumadeathsovertime

ImprovementinresuscitationandthechangingepidemiologyoftraumadeathsovertimeHemodynamic

MornitoringIn1959,Guytondescribedtherelationshipbetweenleftatrialpressureandtheevolutionofpulmonaryedema.Stillhavenomethodofdeterminingwhichpatientsrequiredfluidandwhatquantities.In1970,thePAC,Swan-Ganz

CommercialIVfluids↓PolyvinylIVcatheters↓IntensiveCare↓DecreasingUSInfantdeaths/100,000fromhypovolemicshock输液的时机与剂量Han报道：休克病人血压恢复延迟1小时，毛细血管再充盈小于2秒，死亡率增加因此在基层医院有效、快速的液体复苏有明显的时间效应，非常重要

HanYY,2003;Pediatrics112:793-799

液体治疗的时机液体复苏开始的时间是液体复苏研究的热点和难点针对不同的患者,应该早期还是晚期进行液体复苏,甚至该不该液体复苏都存在很多争议limitingthetidalvolumeinALI(acutelunginjury)orARDS(acuterespiratorydistresssyndrome)Earlygoal-directedtherapyUseofdrotrecogin

alfa(activated)UseofmoderatedosesofsteroidsTightcontrolofbloodsugar

Jean-LouisVincent,EdwardAbraham,Djillali

Annane,GordonBernard

EmanuelRivers,GreetVandenBergheReducingmortalityinsepsis:newdirections

Earlygoal-directedtherapy(EGDT)

RiversE,etal.NEJM2001,345:1368-1377Earlygoal-directedtherapy(EGDT)RiversE,etal.NEJM2001,345:1368-1377Earlygoal-directedtherapy(EGDT)RiversE,etal.NEJM2001,345:1368-1377严重感染的早期目标治疗

EarlyGoal-DirectedTherapy,EGDT

RiversENEnglJMed2001;345:1368-77CVP=8-12mmHg平均动脉压＞65mmHgScvO2＞70%尿量＞0.5ml/kg/h容量是否足够？灌注压是否恰当？组织氧供是否充足？脏器灌注如何？获得足够的DO2：CVP(前负荷)和MAP(后负荷)导向的容量治疗恢复全身DO2与氧需的平衡：ScvO2为导向，纠正全身组织缺氧改善组织器官灌注：尿量为导向，纠正肾脏等器官低灌注前6小时复苏目标Doyouknowsepsisdefinitions?

在一个国际性的调查中

只有

22％(114of529)

的

ICU医生和5％(26/529)

其他内科医师可以明确的说出ACCP/SCCM

的

sepsis定义

(P<0.0001)

Aninternationalsepsissurvey:astudyofdoctors'knowledgeand

perceptionaboutsepsis

CriticalCare2004,8:R409-R413

感染性休克临床指南的调查-认知与执行方法：采用问卷调查的方式针对指南内容提出问题，问题主要为6小时内早期容量复苏的综合治疗，

EGDT、CVP、血乳酸、Scvo2、广谱抗生素的及时应用、应用抗生素前的相应培养。同时还有24小时内的综合治疗,包括小剂量激素的应用、严格的血糖控制、平台压的控制。

ChineseCriticalCareMedicine2008UnderstandSSCguidelinesChineseCriticalCareMedicine2008(Unpublished)

乳酸的应用83％认为乳酸重要51％科室可以自己检测乳酸41.7％经常监测乳酸开始时机种类选择液体量液体治疗存在的问题Analysis2:colloidandhypertoniccrystalloidversusisotoniccrystalloid(outcomedeaths)studyn/NtreatmentcontrolRRsubtotalRR(95%CI)AlbuminorPPF14/1

770.50[0.06-4.33]HES000notestimableModifiedgeltatin000notestimableDextran1283/86676160.88[0.74,1.05]

0.01o.1110100FavorscolloidfavorscrystalloidPerel

P,RobertsI.CochraneDatabaseofSystRev2007.Analysis3:Colloidversushypertoniccrystalloid(outcomedeaths)studytreatmentcontrolRRsubtotalRR(95%CI)AlbuminorPPF

19

197.0[0.39-126.92]HES88notestimableModifiedgeltatin1010notestimableDextran00notestimable

0.01o.110100FavorscolloidfavorscrystalloidPerel

P,RobertsI.CochraneDatabaseofSystRev2007.输液的种类-晶体与胶体的争论Sevenmisconceptionsregardingvolumetherapystrategies—andtheircorrection

Firstmisconception:salineisaphysiologicalsolution

Secondmisconception:albuminissuperiortootherplasmasubstitutes

Thirdmisconception:allcolloidsarethesame

Fourthmisconception:crystalloidsareaseffectiveascolloids

Fifthmisconception:useofpressure-relatedmonitoringvariablestoguidevolumetherapy

Sixthmisconception:mortalityistheonlyvariablethatcountsforassessingthequalityofvolumereplacementstrategies

Seventhmisconception:themythofmeta-analyses

BritishJournalofAnaesthesia103(2):147–51Firstmisconception:salineisaphysiologicalsolution

Withitshighsodium(154mmol/litre)andhighchloride(154mmol/L)concentrations,itisfarfrombeingaplasma-adaptedsolution(hyperchloraemic)acidosisAlthoughtheclinicalimportanceofmetabolicacidosishasbeenintensivelydiscussed,thereappearstobenogoodreasonstousesalinesolutiontocorrecthypovolaemia.TheBritishConsensusGuidelinesonIntravenousTherapyforAdultSurgicalPatients10recentlyrecommendedthat‘...balancedsolutions...shouldreplace0.9%saline...(Evidencelevel1b)’合成血管内118g丢失每天丢失0.3g13.6g/d(3.8%/d1)每天丢失13.3g(3.7%/d)4.5%/d血管外242g交换177g其他65gSecondmisconception:albuminissuperior

tootherplasmasubstitutes白蛋白的应用扩容纠正低蛋白血症TheSAFEStudy

Finferetal,NEJM2004;350:2247-56LargeprospectivestudyoftheANZICSgroupANZICS工作组的大型前瞻性研究Multi-center,randomized,double-blind

多中心，随机，双盲6997ICUpatientsrandomizedtoeither4%albumin(n=3497)ornormalsaline(n=3500)forallresuscitations6997个ICU病人随机分为两组，分别给于4%白蛋白和生理盐水进行复苏Primaryend-point28daymortality

首要的终点为28天死亡率TheSAFEStudy

Finferetal,NEJM2004;350:2247-56白蛋白:生理盐水死亡率

726:729(RR0.99)相似的方面治疗之后的器官衰竭ICU住院天数Hospital住院天数机械通气时间CRRT结论:白蛋白在ICU病人的治疗结果同生理盐水无差异Q:这能说明晶体和胶体是一样的吗?RelativeRiskofDeathfromAnyCauseamongAllthePatientsandamongthePatientsintheSixPredefinedSubgroupsTheSAFEStudyInvestigators,.NEnglJMed2004;350:2247-2256SalineorAlbuminforFluidResuscitationinPatientswithTraumaBrainInjury

SAFEStudy-NEnglJMed2007；357：874-884SalineorAlbuminforFluidResuscitationinPatientswithTraumaBrainInjury

SAFEStudy-NEnglJMed2007；357：874-884第一天2组液体平衡有显著差异第2-4天血白蛋白浓度有显著差异SalineorAlbuminforFluidResuscitationinPatientswithTraumaBrainInjury

SAFEStudyNEnglJMed2007；357：874-884SalineorAlbuminforFluidResuscitationinPatientswithTraumaBrainInjury

SAFEStudyNEnglJMed2007；357：874-884GCS分越低，输白蛋白病死率越高SalineorAlbuminforFluidResuscitationinPatientswithTraumaBrainInjury

SAFEStudy-NEnglJMed2007；357：874-88428天生存率2年生存率白蛋白显著增加脑外伤病人的病死率！白蛋白-一个没讲完的故事

这些资料提示，应尽快对重症患者使用白蛋白情况进行回顾性分析，除随机对照临床研究外不应该使用白蛋白,但仍有许多学者坚持对低蛋白血症的危重病人输白蛋白，并坚持认为可以改善病人预后Thirdmisconception:allcolloidsarethesameColloidsolutionsforfluidresuscitationBunnF,etal.

CochraneDatabaseofSystRev2008比较不同胶体在危重病人液体复苏中的效果目的检索各大数据库2007年3月以前有关各种胶体相互比较的RCTs以及quasi-RCTs进行系统评价方法一共检出70个合格的研究,一共纳入4375例结果

结论没有证据表明某一种胶体比另一种更有效或者更安全.ColloidsolutionsforfluidresuscitationBunnF,etal.CochraneDatabaseofSystRev2008.

studyNntotalRR(95%CI)

AlbuminorPPFvsHES25

12341.14[0.91-1.43]AlbuminorPPFvsgelatin76360.97[0.68,1.39]AlbuminorPPFvs

dextran43603.75[0.42,33.09]Gelatinvs

DextrannotestimableGelatinvsHES1813371.0[0.8,1.25]HEvs

Dextrannotestimable

0.10.5151050IntensiveInsulinTherapyandPentastarchResuscitationinSevereSepsisBrunkhorst

FM,etal.NEnglJMed2008.P=0.48P=0.09SecondaryOutcomes

Ringer‘slactateHESn=274n=262Mean95%CIMean95%CIpSOFAScore7.57.1-8.08.07.5-8.5SOFAsubscoreCardiovascular1.761.00-2.711.800.86-2.670.51Respiratory2.572.00-2.892.502.00-2.900.58Coagulation0.110-0.830.460-1.3<0.001Renal0.420-1.330.670-1.940.02Hepatic0.110-0.900.090-0.851.0CNS1.00.05-2.01.00.09-2.430.5Brunkhorst

FM,etal.NEnglJMed2008.CumulativeEffectofVolumeResuscitationontheNeedforRenal-ReplacementTherapyandtheRateofDeathat90DaysBrunkhorst

FM,etal.NEnglJMed2008.Brunkhorst

FM,etal.NEnglJMed2008.结论在脓毒症病人使用HES是有害的,而且与剂量呈正相关Thirdmisconception:allcolloidsarethesameThirdmisconception:allcolloidsarethesameColloidalplasmasubstitutesmayalsopossesseffectsonorganperfusion,microcirculation,tissueoxygenation,inflammation,endothelialactivation,andcapillaryleakagethatgobeyondtheirsimplevolumereplacingproperties.Atpresent,noconvincingbeneficialeffectsonperfusion,inflammation,tissueedema,ororganfunctionhavebeendemonstratedinhumans.Insummary,colloidsdiffergreatlywithregardtotheirhaemodynamicefficacy,theirside-effects,andtheiradditionalnon-volumereplacingpropertiesThirdmisconception:allcolloidsarethesameThisleadstotherecommendation

oftheBritishConsensusGuidelinesonIntravenous

TherapyforAdultSurgicalPatientsthat‘...Hetastarch

andpentstarchMw200kDashouldbeavoidedin

patientswithsepsis....(Evidencelevel1b)’Intheconclusionthatthereisnotenoughconvincingevidenceagainstthereasonableuseof6%HES130/0.4.Analysis1:colloidversuscrystalloid（outcomedeaths）

AlbuminorPPF7754/23

387038841.01[0.92-1.01]HES637/163752621.05[0.63,1.75]

Modifiedgeltatin506/112242820.91[0.49,1.72]

Dextran834/94124221.24[0.94,1.65]

studyn/NcolloidcrystalloidRRsubtotalRR(95%CI)

0.01o.1110100FavorscolloidfavorscrystalloidPerel

P,RobertsI.CochraneDatabaseofSystRev2007.Fourthmisconception:crystalloidsareas

effectiveascolloidsIntheadult,isotoniccrystalloidsolutionsdistributewithintheintravascular(20–25%)andinterstitial(75–80%)space.CrystalloidsprovidenoCOPorevenreduceitbydilution.Thus,muchmorecrystalloidthancolloidisrequiredtocorrecthypovolaemiaandthereisincreasingriskofproducingtissueedemaformation.Inspiteofmuchlowerhaemodynamicefficacyandtheriskofproducingtissueoedema,mostrecommendationsfortreatingthecriticallyillregardedcrystalloidsequaltocolloidsFourthmisconception:crystalloidsareas

effectiveascolloidsInpatientsundergoingmajorabdominalsurgery,theinfluenceofHES130/0.4ontissuePO2wascomparedwiththatinpatientswhoreceivedRL.Systemichaemodynamicsremainedunchangedandweresimilarinbothgroups;tissuePO2increasedsignificantlyintheHES-treatedpatients,butdecreasedsignificantlyintheRLgroup.Inadditiontoitslessbeneficialeffectsonmacro-andmicrocirculation,experimental,animal,andhumanstudiesdocumentednegativeeffectsofcrystalloidsoninflammation,endothelialactivation,capillaryleakage,andedemaformation输注晶体液应注意的问题手术、创伤后输注的晶体液可以积蓄在组织间隙，48-72小时后由于毛细血管通透性的恢复，随着血液中胶体渗透压的升高返回血浆。如果患者的心脏、肾脏功能不能代偿，此时将会发生高血容量和肺水肿，出现呼吸衰竭。Bockjcetal.AnnSurg1998;210:395-405人工胶体Addyourtitleinhere可以引起瘙痒等类过敏反应、急性肾功能损害以及凝血功能障碍人工胶体扩容效果肯定不能改善病人的预后各种人工胶体之间进行比较,并没有充分的证据证明哪一种更好Fifthmisconception:useofpressure-related

monitoringvariablestoguidevolumetherapyFillingpressures(centralvenouspressureandpulmonaryarteryocclusionpressure)havebeenshowntobemisleadingsurrogatesforaccuratelyassessingleftventricularpreload.Cardiacfillingpressuresareinfluencedbyseveralfactorsotherthanvolumeload,includingalterationsinvascularorventricularcompliance.Measurementofintrathoracicbloodvolume(ITBV)hasbeenreportedtobeabettermethodtomonitorvolumereplacement.ITBV,however,isonlyastaticsurrogatemeasureoffillingconditionsandnotofthedynamicprocessofbloodflowandperfusion.Fifthmisconception:useofpressure-related

monitoringvariablestoguidevolumetherapyMonitoringofcardiacoutput(CO)andcentralvenousoxygensaturation(ScvO2)areregardedtobemorereliablemeasuresforassessingtheadequacyofvolumereplacementtherapythansimplepressuremonitoring.Individualgoal-directedvolumetherapyusingdynamicvariablessuchasCOandScvO2hasshownsignificantimprovementinpatients’outcomeSixthmisconception:mortalityistheonlyvariablethatcountsforassessingthequalityofvolumereplacementstrategiesMortalityinmostsurgeryisverylow,thusitisratherunlikelythataspecificvolumereplacementstrategywouldsignificantlyinfluencemortality.InviewofthecomplexityoftheunderlyingdiseaseoftheICUpatientandthemanydifferentdrugstheICUpatientreceives.Withdifferentvolumereplacementstrategies,mortalityhasneverbeenshowntobethemajoroutcomevariable.Whenassessingthevalueofdifferentvolumereplacementmethods,wehavetolookmorecloselyatoutcomevariablessuchaspatientcomfort,organfunction,circulatoryimprovement,inflammatoryresponse,unwantedadverseeffects,orcosts.Seventhmisconception:themyth

ofmeta-analysesThereareanumberofproblemswithmeta-analyses,includingdistinguishingbetweenthedifferentplasmasubstitutes,differentpatientgroups(e.g.typeofsurgery,sepsis,age,andco-morbidity),theuseofdifferentend-pointsforanddurationofvolumeadministration,cleardefinitionsofoutcomeandadverseeffects.失血引起血压过低所致继发脑损伤甚至死亡早期大量补液引起继发出血量增加不同创伤，液体复苏的目标不同液体量液体治疗目标难以确定血流动力学监测的限制开放性还是限制？It’saquestion!ComparisonofTwoFluid-ManagementStrategiesinAcuteLungInjuryNEJM354:2564-2575ComparisonofTwoFluid-ManagementStrategiesinAcuteLungInjury

NEJM354:2564-2575ComparisonofTwoFluid-ManagementStrategiesin