关注危重病人液体平衡定稿.ppt

1、关注危重病人液体平衡,徐颖鹤,目录,EGDT提高抢救成功率 液体超负荷增加危重病人死亡率 CVP监测能准确指导液体复苏吗？ 白蛋白用于液体复苏新观点,Early Goal-Directed Therapy (EGDT): involves adjustments of cardiac preload, afterload, and contractility to balance O2 delivery with O2 demand,Chest 1992;101:1644.,Early Goal-Directed Therapy in the Treatment of Severe Sepsi

2、s and Septic Shock,Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. NEJM 2001;345:1368.,Study purpose: to evaluate the efficacy of early goal-directed therapy in patients presenting to an emergency department with severe sepsis or

3、septic shock (prior to ICU admission) Study design: prospective, randomized controlled, partially blinded, single center trial,CVP 8-12 mm Hg MAP 65 mm Hg Urine Output 0.5 ml/kg/hr,CVP 8-12 mm Hg MAP 65 mm Hg Urine Output 0.5 ml/kg/hrScvO2 70% SaO2 93% Hct 30%,Antibiotics given at discretion of trea

4、ting clinicians,ICU MDs blinded to study treatment,NEJM 2001;345:1368-77.,At least 6 hours of EGDT Mean 8hrs,CVP: central venous pressure MAP: mean arterial pressure ScvO2: central venous oxygen saturation,Early Goal-Directed Therapy,NEJM 2001;345:1368-77.,49.2%,33.3%,0,10,20,30,40,50,60,Standard Th

5、erapy N=133,EGDT N=130,P = 0.01*,*Key difference was in sudden CV collapse, not MODS,Early Goal-Directed Therapy Results:28 Day Mortality,Sudden CV Collapse,MODS,21% vs 10% p=0.02,22% vs 16% P=0.27,NEJM 2001;345:1368-77.,Mortality,质疑点,质疑点,质疑点,CVP监测能准确指导液体复苏吗？,Objective: A systematic review of the li

6、terature to determine the following: the relationship between CVP and blood volume, the ability of CVP to predict fluid responsiveness, the ability of the change in CVP (CVP) to predict fluid responsiveness.,The pooled correlation coefficient between the CVP and measured blood volume was 0.16 (95% C

7、I, 0.03 to 0.28; r= 0.02).,1、The pooled correlation coefficient between baseline CVP and change in stroke index/cardiac index was 0.18 2、The pooled area under the ROCcurve was 0.56 3、The pooled correlation between CVP and change in stroke index/cardiac index was 0.11 4、The baseline CVP was 8.7 -2.3m

8、m Hg in the responders, as compared to 9.7 - 2.2mm Hg in nonresponders (not signficant; p 0.3).,结论,1、CVP与血容量之间相关性很低 2、CVP或者CVP没有能力判定补液对血流动力学的影响 3、CVP不应该用于医生决策液体治疗,Fluid Resuscitation in Septic shockA Positive Fluid Balance and Elevated Central Venous Pressure Are Associated With Increased Mortality,

9、回归性分析 The Vasopressin in Septic Shock Trial (VASST) study 778为感染性休克患者 研究目的是确定CVP、液体平衡与死亡率关系,Crit Care Med.2011;39(2):259-65,12h液体平衡与CVP有关联，24小时就没有关联,Stop filling patients against central venous pressure, please!*,Crit Care Med 2011 Vol. 39, No. 2,Lees N, Hamilton M, Rhodes A: Clinical review: Goal-d

10、irected therapy in high risk surgical patients. Crit Care 2009; 13:231,修正的EGDT试验 1.镇静镇痛 2.液体反应性：CVP动态变化；对于正压通气患者SVV/PPV 3.滴定MAP7585mmHg 4.P(cv-a)CO2 5.血管活性药撤离试验,血管活性药物撤离试验,液体超负荷，我们要重视的问题！,Payen S, etal,for the Sepsis Occurrence in Acutely Ill Patients (SOAP)Investigators: A positive fluid balance is

11、 associated with a worse outcome in patients with acute renal failure. Crit Care 12: R74, 2008,液体积聚在为重病人中经常发生,Fluid Resuscitation in Septic shockA Positive Fluid Balance and Elevated Central Venous Pressure Are Associated With Increased Mortality,回归性分析 The Vasopressin in Septic Shock Trial (VASST) s

12、tudy 778为感染性休克患者 研究目的是确定CVP、液体平衡与死亡率关系,Crit Care Med.2011;39(2):259-65,12h液体正平衡4.2 3.8 L 第四天液体正平衡11 8.9 L,1、2与4相比，死亡率下降 3与4相比，有下降，但无统计学意义,结论：液体超负荷增加死亡风险,Vincent JL,et al: Sepsis in European intensive care units: results of the SOAP study. Crit Care Med 2006; 34:344353.,多因素回归分析表明：入院72小时液体平衡时独立的结果预测指标

13、：没增加1升的液体积聚，死亡风险增加,Fluid accumulation survival and recovery of kidney function in critically ill patients with acute kidney injury.,目的: If fluid accumulation is associated with mortality and non-recovery of kidney function in critically ill adults with acute kidney injury. 方法: Fluid overload was def

14、ined as more than a 10% increase in body weight relative to baseline, measured in 618 patients enrolled in a prospective multicenter observational study.,Kidney Int 2009,618 critically ill patients were examined the effect of fluid overload,Figure 2. Mortality rate by final fluid accumulation relati

15、ve to baseline weight and stratified by dialysis status. Reprinted from reference 20, with permission.,a highly significant correlation was observed between mortality and the proportion of days in which fluid overload was present (P0.0001). 结论： In patients with acute kidney injury, fluid overload wa

16、s independently associated with mortality.,The importance of fluid management inacute lung injury secondary to septic shock Chest 2009; 136: 102109,Adequate initial fluid resuscitation 是6h内给予大于20 ml/kg 液体和CVP大于 8 mm Hg. Conservative late fluid在7天内有2天达到液体平衡或负平衡,多因素回归分析不能达到限制液体管理的是独立的死亡危险因素,Wiedemann,

17、-two fluid-management strategies, N Engl J Med ,2006,PURPOSE: Optimal fluid management in patients with acute lung injury METHODS: compared a conservative and a liberal strategy of fluid management,结论: the conservative strategy of fluid management improved lung function and shortened the duration of

18、 mechanical ventilation and intensive care without increasing nonpulmonary-organ failures.,液体超负荷,疾病严重、死亡,病理因素,生物标记,1、渗漏 2、AKI 3、心衰 4、CVP误导 .,1、心脏负荷增加 2、肺水则更多 3、机械通气时间长 4、肾脏静水压增加-肾动脉灌注少 5、腹腔间隙综合症影响肾功能,Clin J Am Soc Nephrol 5: 733739, 2010.,对我们的提示,1、尿量少不是扩容的绝对指证，扩容有预防AKI的作用，也可能带来不好的结果。 2、补液不能改善肾功能和氧合，

19、即要停止 3、对感染性休克在前6小时积极液体复苏有益，当病情进展，需要控制液体输入， 4、可在利尿剂有效前提下使用利尿剂，利尿剂无效，要及时改为CRRT,白蛋白，老话题，新进展？,维持血浆胶体渗透压（）。的由白蛋白完成，并在循环血液与细胞外液之间动态交换，维持血液与细胞外液的胶体渗透压的平衡。 物质转运作用。是脂类、激素、酶、电解质、维生素、药物等许多物质转运的最重要的载体。 是体内重要的自由基清除剂。但是，这一功能在危重病的意义尚不清楚 。 其他功用。调节细胞凋亡、抗凝、维持酸碱平衡等。,白蛋白的生理作用,的。 白蛋白静脉输注后分钟内可将.倍体积的水分吸入血循环。 是人体细胞外液中含量最多的

20、蛋白质，具有亲水性，可以自由通过毛细血管壁。 正常更新稳定，每天大约。 半衰期天，平均天。,白蛋白的生理作用及特点,30-40%的危重病人 均发生低白蛋白血症 ！,低蛋白血症 增加危重病人死亡率吗？,血浆白蛋白含量不仅仅是患者的营养指标，更重要的是危重患者并发症和病死率的重要预测指标,Mangialardi等总结了北美7个ICU的临床资料，表明低白蛋白血症与ARDS的发生率和病死率显著相关。 根据一项队列研究所做的分析，危重病患者血清白蛋白浓度每下降2.5 g/L，可增加24%26%的死亡危险，调整了危险因素和基础疾病以后,这种危险依然存在。 从Medline、Cochrane Library

21、和EMBASE等数据库收集到的71份组群研究提示：血清白蛋白浓度与患者的预后和病情严重程度密切相关。白蛋白低于25 g/L的危重患者并发症发生率将提高4倍，病死率升高6倍。绝大部分危重患者死亡前的血浆白蛋白都难纠正到正常水平。,是否需要补充白蛋白？,缺什么补什么，天经地义！,缺什么补什么，真的是天经地义吗？,令人失望的结果,Foley等：给予白蛋白，并使其血白蛋白g/L，与不给予白蛋白的对照，病死率、住院日、住时间、机械通气时间均无差异。 Golub和Rubin的研究结果与之相似。,Foley E F,BorlaseB C,DzikW H,et al.Albumin supplementati

22、on in the criticallyill: a prospective, randomized trialJ.Arch Surg,1990,125:739 742 Golub R, Sorrento J J, Cantu R, et al.Efficacy of albumin supplementation inthe surgical intensive care unit: aprospective, randomized studyJ.CritCareMed,1994,22:613 619. Rubin H, Carlson S, DeMeo M, et al.Randomize

23、d, doubled2blindstudy ofintervenous human albumin in hypoalbu2minemicpatients receiving totalparenteralnutritionJ.Crit CareMed,1997,25:249252.,危重病患者接受人体白蛋白:随机对照研究的系统评价,Cochrane协作网创伤协作组完成 系统评价一共纳入了32项随机对照试验(RCT) 使用白蛋白组与对照组相比,死亡相对危险升高约1.68倍,死亡率增加约6% 烧伤患者中,死亡危险更趋明显(RR=2.40) 在低蛋白血症患者亚组, 虽然差异没有统计学意义,但接受白

24、蛋白治疗的患者中,死亡率仍呈现上升趋势,轩然大波的文章 1998年英国医学杂志 （BMJ1998； 317:235-240 ）,结论：没有证据证明给予白蛋白可降低包括低血容量、烧伤或低白蛋白血症等危重病人的死亡率。相反,强烈提示其可增高死亡率,输注白蛋白不能改善患者预后的可能原因,适应性反应。 蛋白质结合的重要性受到了质疑。 血管内皮通道开放，白蛋白渗漏到组织间隙中，血管外的白蛋白还可以进入到不能发生交换的部位，如肠壁以及手术或创伤的伤口。 白蛋白结构的改变。 白蛋白可以通过主动运输进入细胞内。 白蛋白及其替代品对血液的影响 。,2001年, Wikes等另一个基于RCT的系统评价在Ann I

25、ntern Med上发表,415个相关研究中纳入了55项符合标准的RCT 白蛋白治疗组与对照组相比,其死亡率相对危险(RR)为1.11,意味着白蛋白治疗并不增加死亡风险 外科手术或创伤、低蛋白血症、腹水等)进行的亚组分析,结果也都未证明白蛋白治疗与死亡风险相关,系统评价的价值就正在于揭示问题和为下一步的研究提出方向,The SAFE study investigators. A comparison of albumin and saline for fluid resuscitation in the intensive care unit,在澳大利亚和新西兰完成的前瞻性、多中心、随机、双盲试验包括16个ICU 的6 997例患者。 3 500例患者接受生理盐水治疗,3 497例患者接受4%白蛋白治疗,NEnglJMed,2004,350:2247 2256,白蛋白和生理盐水在容量复苏中的比较研究,结论：在ICU中，用4%白蛋白和生理盐水做液体复苏结果是一样的,Sepsis occurrence in acutely ill patients: