围术期液体治疗的进展PPT学习教案

1、会计学1围术期液体治疗的进展围术期液体治疗的进展n第2页/共89页入量出量胶体液佳乐施4500出血18000万汶5500尿量3800血浆2000血小板400血液自体回收血6600库血3800晶体液LR6500NS1800总入量32200总出量21800术中液体平衡：术中液体平衡：+10400mL第3页/共89页入入ICU23：2023日日8Am24日日8Am25日日8Am26日日8Am27日日8Am28日日8Am29日日8Am入量入量人工胶体人工胶体10000自体回收血自体回收血6600血血制制品品血浆血浆2000600200血小板血小板400200白蛋白白蛋白100200200红细胞红细胞3

2、800400晶体液晶体液8300694245218732920160113411163鼻饲鼻饲44094012201630出量出量出血出血18000尿尿3800520494045803950405041504200引流引流25055010010050总入量总入量32200794395225732910254131613167总出量总出量21800770549046804050410041504200出入量差值出入量差值+10400+24-1538-2107-1140-1558-989-2357病例介绍：术后液体平衡情况病例介绍：术后液体平衡情况术后第17天液体总平衡 9665 mL第4页/共8

3、9页病例介绍：术后胸部病例介绍：术后胸部X线片变化线片变化6.23(术后第1日)6.28(术后第6日)6.26(术后第4日)第5页/共89页病例介绍：术后一般生命体征变化病例介绍：术后一般生命体征变化项目项目入入ICU23:2023日日8Am24日日8Am25日日8Am26日日8Am27日日8Am28日日8Am29日日8Am30日日8AmTC3837.83636.936.836.438.537HR897298817879698964BP134/77104/60115/71109/64123/69141/75122/63114/66119/67CVP1312111011710SpO2100969

4、894989797100100R131012171715141414第6页/共89页病例介绍：术后动脉血气变化病例介绍：术后动脉血气变化项目项目入入ICU23:2023日日8Am24日日8Am25日日8Am26日日8Am27日日8Am28日日8Am29日日8Am30日日8AmModeBilevelCPAPSpontFiO21004060704550504030PEEP55810108850pH7.297.367.517.497.437.487.517.447.39PaCO237.442.429.633.438.642.942.637.039.4PaO2189.474.5124.685.695.

5、082.387.4101.182.3BE-8.1-2.21.22.437.19.40.8-1.4PaO2/FiO2189.4186.2207.7122.3211.1166.4218.5252.7274.3第7页/共89页术后情况术后情况n第8页/共89页第9页/共89页Moore FD. Metabolic care of the surgical patient. Philadelphia: WB Saunders, 1959.外科应激 水钠潴留 围术期应限制液体入量?第10页/共89页Shires T, Ann Surg 1961;154:80310“第三间隙第三间隙” 的细胞外液丢失的细

6、胞外液丢失第11页/共89页第12页/共89页时间补偿输液量缺失量 维持量 失血第三间隙本小时输液量累计输液量 诱导前35022011000680680切皮前220110003301010第一小时2201103003509801990第二小时2201103003509802970第三小时2201101503508303800第四小时-11002003304130术前Hb 15g/dL, 禁食10hs, 维持输液速度110mL/hMiller RD, ed. Anesthesia, 5th ed. 2000:1606 7.第13页/共89页围术期液体治疗围术期液体治疗Lang K, Anesth

7、 Analg 2001; 93: 405-9Christopherson R, Anesthesiology 1993; 79: 422-34Glaser F, Ann Surg 1995; 221: 372-80第14页/共89页围术期液体治疗围术期液体治疗Holte K, Br J Anaesth 2002;89: 62232.Kudsk KA. Ann Surg 2003;238:649 50.第15页/共89页第16页/共89页How much harm does excess fluid really cause?第17页/共89页Crit Care Med. 1990 Jul;18

8、(7):728-33. Postoperative fluid overload: not a benign problem.Lowell JA, Schifferdecker C, Driscoll DF, Benotti PN, Bistrian BR. Nutrition Support Service, New England Deaconess Hospital, Harvard Medical School, Boston, MA 02215.第18页/共89页Crit Care Med. 1990 Jul;18(7):728-33. 第19页/共89页Perioperative

9、weight gain and mortality体重增加越多，死亡率越高Crit Care Med. 1990 Jul;18(7):728-33. * P 0.008第20页/共89页CHEST 1999; 115:13711377第21页/共89页第22页/共89页第23页/共89页第24页/共89页第25页/共89页(Anesth Analg 2003;96:1504 9)第26页/共89页(Anesth Analg 2003;96:1504 9)第27页/共89页Hahn RG. Anesth Analg 2007; 105: 304第28页/共89页第29页/共89页毛细血管内静水压

10、毛细血管内静水压毛细血管内胶体渗透压毛细血管内胶体渗透压组织内静水压组织内静水压组织内胶体渗透压组织内胶体渗透压第30页/共89页Aggressive fluid strategies adversely affect every system and organProwle JR et al. Nat Rev Nephrol 2010;6:107第31页/共89页第32页/共89页CVP5 mmHg)Journal of Clinical Anesthesia 14:252256, 2002第33页/共89页Journal of Clinical Anesthesia 14:252256,

11、2002第34页/共89页Journal of Clinical Anesthesia 14:252256, 2002第35页/共89页Journal of Clinical Anesthesia 14:252256, 2002第36页/共89页Journal of Clinical Anesthesia 14:252256, 2002第37页/共89页(Ann Surg 2003;238: 641648)第38页/共89页(Ann Surg 2003;238: 641648)第39页/共89页(Ann Surg 2003;238: 641648)第40页/共89页(Ann Surg 2003

12、;238: 641648)第41页/共89页(Ann Surg 2003;238: 641648)P0.001第42页/共89页(Ann Surg 2003;238: 641648)第43页/共89页限制性液体治疗改善病人预后限制性液体治疗改善病人预后?第44页/共89页 术中液体治疗对术后生理功能恢复和预后的影响 32例病人，择期结肠手术 限制输液组 median 1640 ml (range 9352250 ml) 自由输液组 median 5050 ml (range 35638050 ml)British Journal of Anaesthesia 99 (4): 5008 (200

13、7)第45页/共89页Protocol of fluid administration and patient managementBritish Journal of Anaesthesia 99 (4): 5008 (2007)第46页/共89页Effect of fluid therapy on postoperative pulmonaryfunctionBritish Journal of Anaesthesia 99 (4): 5008 (2007)第47页/共89页Effect of fluid therapy on nightly postoperative hypoxaemi

14、a第48页/共89页Postoperative data第49页/共89页British Journal of Anaesthesia 99 (4): 5008 (2007)第50页/共89页液体负荷与围术期并发症的关系第51页/共89页第52页/共89页第53页/共89页No association between these two variables (r =0.27). The correlation between CVP and change in blood volume was 0.1 (r2 =0.01).Crit Care Med 1984; 12:107112第54页/共

15、89页CHEST 2008; 134:172178)第55页/共89页CHEST 2007; 132:18171824.O2ERe=(SaO2-ScvO2/SaO2)第56页/共89页第57页/共89页Therapeutic interventionsTotalIntraopPostopCHEST 2007; 132:18171824.第58页/共89页第59页/共89页Number and type of organ failures住院时间：住院时间：(11.3 3.8) days vs (13.4 6.1) days, p0.05CHEST 2007; 132:18171824.第60页

16、/共89页CHEST 2007; 132:18171824.第61页/共89页Critical care 2010,14:R18第62页/共89页Critical care 2010,14:R18第63页/共89页Critical care 2010,14:R18第64页/共89页Critical care 2010,14:R18第65页/共89页Critical care 2010,14:R18住院时间明显缩短第66页/共89页Critical care 2010,14:R18第67页/共89页Anesthesiology 2002; 97:8206第68页/共89页Intraoperati

17、ve fluid managementalgorithmAnesthesiology 2002; 97:8206第69页/共89页Incidence of Postoperative ComplicationsAnesthesiology 2002; 97:8206第70页/共89页Anesthesiology 2002; 97:8206 目标引导液体治疗 促进胃肠功能恢复 减少PONV发生 缩短住院时间第71页/共89页Br J Anaesth 2005; 95: 63442第72页/共89页Br J Anaesth 2005; 95: 63442第73页/共89页Postoperative

18、 hospitalization and recovery of gut funtionBr J Anaesth 2005; 95: 63442第74页/共89页Br J Anaesth 2005; 95: 63442第75页/共89页Br J Anaesth 2005; 95: 63442第76页/共89页Anaesthesia, 2008, 63, pages 4451第77页/共89页ICU admissionsAnaesthesia, 2008, 63, pages 4451目标引导治疗减少需入ICU病人数量第78页/共89页Return of bowel functionAnaesthesia, 2008, 63, pages 4451目标引导治疗加速术后胃肠道功能恢复第79页/共89页Overall rate of complicationsAnaesthesia, 2008, 63, pages 4451目标引导治疗减少术后并发症发生率第80页/共89页Hospital stayAnaesthesia, 2008, 63, pages 4451目标引导治疗缩短术后住院时间第81页/共89页Phan TD et al. J Am Coll Surg 2008; 207: 935第82页/共89页