目标导向的液体治疗

1、目标导向液体治疗Goal-directedfluidtherapy复旦大学附属中山医院麻醉科薛张纲Moore(1959)外科应激一应激一水钠创伤反应激素T潴留围手术期应当限制液体输入Shires(1961)大手术液体 转移Q 用晶体液补充第三间隙液体的丢失.生理需要量：晶体液.术前液体丧失量：晶体液.液体再分布：晶体液.麻醉后血管扩张：晶体液或（和）胶体液.术中失血：晶体液、胶体液和血制品是麻醉科医生输液的准则，但合理吗?主张限制输液者认为避免大量的液体进入组织间隙降低心肺并发症及伤口感染发生率加速胃肠道功能的恢复缩短住院时间降低并发症的发生率与死亡率LoboDN,etal.Lancet200

2、2;359:181218JoshiGP.AnesthAnalg.2005;101:601BrandstrupB.AnnSurg.2003;238:641648保证有效的组织灌注术中循环稳定术后恶心、呕吐减少术后康复加速HolteK,etal.AnnSurgy2004;240:892AHSZfetal.Anaesthesia92003,58,775-803支持开放输液者的观点r48例ZS4L2级病人，接受AC手术分成开放输液和限制输液组开放40nil/kgLR限制15ml/kgLR观察指标今呼吸、运动能力、心血管激素反应、疼痛、恶心和呕吐、康复和住院时间HolteK,etal.LiberalVe

3、rsusRestrictiveFluidAdministrationtoImproveRecoveryAfterLaparoscopicCholecystectomy,ARandomized,Double-BlindStudy.AnnalsofSurgery,2004,240(5):892-899.TABLE4.DischargeDataandDataFromtheWard15mL/kgLR40mL/kgLRPValueFluidintake6ampreoperatively175(0-175)175(0-175)0.98Oralfluidintake(0-4hours)537.50(175-

4、1175)725(175-1500)0.04Fulfillingdischargecriteria(PADDSn9)onthedayofsurgery16/823/10.01Dischargeondavofsurerv(fromootentiallvdischargeableDatients)15/2321/220.02Morphineconsumption(4hpostoperatively)Patientsrequiring640.51Totaldose(mg)0(0-30)0(0-30)0.42Ondansetron(4hpostoperatively)Patientsrequiring

5、101.00Totaldose(mg)4(OY)0(0-0)0.32开放输液组术后进食早，手术当天符合出院标准和出院人数明显大于限制输液组HolteK,etal.LiberalVersusRestrictiveFluidAdministrationtoImproveRecoveryAfterLaparoscopicCholecystectomy,ARandomized,Double-BlindStudy.AnnalsofSurgery,240(5):892-899.3.75(D? quad (TUIEDEBd(号)P2 Pl 3M开放输液组术后肺功能和运动能力都明显优于限制输液组HolteK,

6、etal.LiberalVersusRestrictiveFluidAdministrationtoImproveRecoveryAfterLaparoscopicCholecystectomy,ARandomized,Double-BlindStudy.AnnalsofSurgery,2004,240(5):892-899.然而，术中输液过多可以导致组织水肿临床液体治疗的最终目的是今术中液体治疗的最终目标是避免输液不足引起的隐匿性低血容量和组织低灌注，及输液过多引起的心功能不全和外周组织水肿今必须保证满意的血容量和适宜的麻醉深度，对抗手术创伤可能引起的损害，保证组织灌注满意，器官功能正常Im

7、portantperioperativeaim:AvoidanceofedemaExample:Abdominalhypertension主张限制输液者的观点（1）20例正常的病人，行大肠手术分组今标准液体输注（231上入S2L5%GS）今限制液体输注（W2L,0.5LNS,L5L5%GS）比较终点今体重、尿量、电解质、胃肠动力和其它并发症LoboDN,etaLEffectofsaltandwaterbalanceonrecoveryofgastrointestinalfunctionafterelectivecolonicresection:arandomisedcontrolledtria

8、l.Lancet2002;359:1812-1854321012(皇1S一MU一Huw。体重静脉补液量(IE)Hp5=snou&lu-jolunoAnE)indu一prl三S01尿钠排出量0(-OIUUJ)lndnoErl-posXJO3U一nStandardgroupRestrictedgroup(n=10)(n二坳Peripheraloedema70Hyponatraemia(NaW1B。mmol/L),40expressedaspatient-daysHypokalaemia(KC3-5mmol/L).21expressedaspatient-daysVomitingonday430Co

9、nfusionafterday130Woundinfection10Respiratoryinfection20Readmissionwithin30days1*0Deathwithin30days1*0Totalnumberofpatientsdeveloping7tItSide-effectsandcomplicationsside-effectsorcomplicationsValuesarenumberofpatients.*Occurredinthesamepatient.Causeofdeath:lymphangitiscarcinomatosiLfp=0-01Fishersexa

10、cttest.Table4:Side-effectsandcomplications两组并发症和30天死亡人数比较两组固体和液体食物排空时间比较50005000502211cs81SEA8ud常osssoswdp=0(i)OS-Busldlu。三seBaseqdpnb二-002-50StandardgroupRestrictedgroupStarxiardgroupRestrictedgroup两组病人终点事件的比较线占一、fl1标准组1限制组1差异P值首次肛门排气（天）4.0(4.0-5.0)3.0(2.0-3.0)0.001首次排便（天）6.5(5.8-8.0)4.0(3.0-4.0)0.

11、001停止静脉输液（天）6.0(4.8-6.3)4.0(3.8-4.0)0.001恢复固体食物（天）6.5(5.5-7.0)4.0(4.0-4.3)0.002术后住院时间（天）9.0(7.8-14.3)6.0(5.0-7.0)0.001Anesthesiology2(X)5;103:25-322(X)5AmericanSocietyofAiwsdiesiologists,Inc.LippincottWilliams&Wilkins,Inc.EffectofIntraoperativeFluidManagementonOutcome(tfterIntraabdominalSurgeryVadim

12、Nisanevich,M.D.；ItamarFelsenstein,GidonAlmogy,CharlesWeissman,M.D.,丰SharonEinav,M.D.,IditMatot,MD|TotalVolumeofFluidAdministeredRestrictiveLiberalProtocolProtocolGroupGroup(n=75)(n=77) TOC o 1-5 h z Intraoperative3,8781,1701,408946*Postoperativeday112,0124752,170476Postoperativeday21,9855342,052492P

13、ostoperativeday31,8704751,955542PerioperativeComplicationsRestrictiveLiberalProtocolProtocolGroupComplicationsGroup(n=75)(n=77)InfacticusResults:ThenumberofpatientswithcomplicationswaslowerintheRPG(P=0.046).PatientsintheLPGpassedflatusandfecessignificantlylater(flatus,medianrange:43-7daysintheLPGvs.

14、32-7daysintheRPG；P0,001；feces：64-9daysintheLPGvs.43-9daysintheRPG;P0.001),andtheirpostoperativehospitalstaywassignificantlylonger(97-24daysintheLPGvs.86-21daysintheRPG;P=0.01).Sign很icantlylargerincreasesinbodyweightwereobservedintheLPGcomparedwiththeRPG(P0.01).Inthefirst3postoperativedays,hematocrit

15、andalbuminconcentrationsweresignifyicantlyhigherintheRPGcomparedwiththeLPG.1UIPulmonaryemboli00RenalRenaldysfunction00Daathn0Totalnumberofcomplications3217Totalnumberofpatientswith2313*complications主张限制输液者的观点（3）病人总数7例，加入随机、双盲对照研究围术期液体治疗分成限制输液和常规输液组限制输液组各种并发症发生率降低“心、肺并发症7%vs24%“组织愈合并发症76%助37%“死亡率Ops4

16、7%结论：择期结直肠手术围术期限制输液有利BrandstrupB,PottF,etal:EffectsofIntravenousFluidRestrictiononPostoperativeComplications:ComparisonofTwoPerioperativeFluidRegimens.ARandomizedAssessor-BlindedMulticenterTrial.AnnalsofSurgery,2003,238,641648.术中限制入液量“硬膜外麻醉无液体负荷“没有第三间隙丢失液的标准替代物“失血替代物一HES1:1术后引流失液量可以HES术后根据体重计算补液量术后优

17、先考虑经口补液RSRSRSRSRSRSRS术后期Day1Day2Day3Day4Day5Day6静脉补液和体重增加的相关并发症100908070605040302010输入液体量n=48n=42n=40增加体重n=52n=435.5L2.5kgEndothelialinjuryfollowingvolumeoverloadingJacobM,etal.Anesthesiology.2006;104:1223-31.RehmMetal.Anesthesiology2001;95:849-856.ImpactofDifferentCrystalloidVolumeRegimesonIntestin

18、alAnastomoticStabilityGoranMarjanovic,MD,*ChristianVillain,*EvaJuettner,MD,tAxelzurHausen,MD,PhD,tJensHoeppner,MD,UlrichTheodorHoptfMD,*OliverDrognitz,MD,*andRobertOhermaier,MD*Theauthorsconcludedthatthevolumeoverload阳卬havedeleteriouseffectsonanastomotichealingandpostoperativecomplicationsinGIsurger

19、ypossiblebecauseofamarkedbowelwalledema.Ann. Surg. 2009; 249(2):181-5EditorialFluidOverloadandSurgicalOutcomeAnotherPieceintheJigsawDileepN.Lobo,DM,FRCSThekeytobetterintravenousfluidtherapyistogivetherightamountoftherightfluidattherighttimeandtotryandinaintainthepatientinastateofzerofluidbalanceasmu

20、chaspossibleAvoidanceoffluidoverload,ratherthanfluidrestrictioqseemstobethekeytobetterpostoperativeoutcome.LoboDN.AnnSurg.2009Feb;249(2):186-8围手术期液体治疗的影响因素及预后morbidity八procedurecomorbiditiespreop hydrationbowel preparationanaesthesia / neuroaxial blockadeT risk of: organ hypoperfusion SIRS sepsis mu

21、lti organ failureT risk。： oedema ileus PONV pulm complications T cardiac demandshypovolaemianormovolaemiahypervolaemia有关液体治疗的推论液体过量有害液体不足同样有害猜测往往会误导临床医生，应当评估而不是猜测液体治疗应采取个体化的原则GoalDirectedFluidTherapy：usingmorepatientdataandfewerassumptions目标导向液体治疗100例病人，随机分成常规输液和目标控制输液组目标控制输液“经食管多普勒监测指导术中补液(FTc,SV)“

22、6%HES以200桃/增加，以达到最佳心排血量进食固体食物的时间分别为47土0.5vs3.。子5天住院时间分别为7士3Vs5于3天术后需要治疗的严重尸QVP分别为36%V514%GanTJ,etal:Goal-directedIntraoperativeFluidAdministrationReducesLengthofHospitalStayafterMajorSurgeiy.Anesthesiology2002;97:820-6.使用与以/Mr指导液体输注FTc-CorrectedFlowTimeSV-StrokeVolumeRandomizedclinicaltrialRandomize

23、dclinicaltrialassessingtheeffectofDoppler-optimizedfluidmanagementonoutcomeafteelectivecolorectalresectionS.E.Noblett1,C.P.Snowden2,B.K.Shenton4andA.F.Horgan3Results:Demographicandsurgicaldetailsweresimilarinthetwogroups.Aorticflowrime,strokevolume,cardiacoutputandcardiacindexduringtheintraoperative

24、periodwerehigherintheinterventiongroup(PMinimally invasive CO/SVyCVPMore invasiveDoppler, TEEWPACath目标导向液体治疗经食管超声多普勒今降主动脉校正血流时间(Correctedflowtime,FTc)今心输出量(CardiacOutput)Ma分析证明今降低围术期并发症的发生今缩短住院时间WalshSR,etal.IntJClinPract2008;62:466AbbasSMyetal.Anaesthesia2008;63:44GanTJyAnesthesiology2002;97:820-6目

25、标导向输液反对者之声今操作复杂，代价昂贵今额外地增加了患者的创伤替代经食管超声多普勒fPPV今APCOSWPinskyMR,etal.CritCareMed,2005;33:1119LopesMRyetal.CritCare2007;11:RI00每搏心排血量变异率（SPP）二飞V由脉搏波曲线卞面积确定2机械通气对动脉血压的影响是生理学的基本*r前负荷反应性的指标：产生的原因：呼吸对动脉血压的影响正常范围今自主呼吸情况下变异的正常范围5-10%“机械通气，潮气量8加冰g8-13%SW预测心脏对容量负荷的反应Theincreaseofpreloadvolumeisequal:AEDV=NEDV2

26、SV2SPP的临床应用S”是一个动态的参数，应当连续监测S”目前仅适用于机械通气的病人S能够预测心脏对容量负荷的反应，其理论依据是Frank-StarlingcurveBerkenstadtetal,EurJAnaesthesiol17(19):4%2000Reuteretal,EurJ.Anaesthesia17(Suppl19):163,2000Reuteretal,BritishJournalofAnaesthesia88(1)1246,2002CardiacOutputFloTracsensor(arterialcatheter)临床使用SW指南是否病员需要调整SV或CO（通过临床检查

27、、SKCO或监测，乳酸水平和肾功能情况等）是否动脉压力波形非常准确？（进行冲洗试验）病员是否存在自主呼吸干扰?潮气量是否,8mL/kg是否心律规则？（非房颤心律）可以测定并参考SFV监测结果指导临床治疗围术期液体管理流程I外科手术危险程度评分I常规监测考虑监测高龄 ASA 3合并症手术范围创伤急诊失血A大量的体液转移启动液体管理流程氐或SW 13%即秘。2（氐考虑补充液体，静脉给予正性肌力药物或缩血管药物考虑输注红细胞、正性肌力药物或缩血管药物基础：补充晶体液57Mz%r,并根据SKSFT和频射。2监测决定额外补液量FloTracHemodynamicAlgorithmwithSW/APCOD

28、ecreasedCOandBPVolumeResponsive:SVV13%HypovolemiaNORMALRANGESCardiacOutput(CO=HRxSV/1000)=4-8LpmCardiacIndex(CI=CO/BSA)=2.5-4.1LpmStrokeVolume(SV=CO/HRxlOOO)=60-100ml/beatStrokeVolumeVariation(SW=SVmax-SVmin/SVmean)=13%StrokeVolumeIndex(SVCFHRxlOOO)=25-45ml/beatAnesthesiology2009:110:496-504Copyriglir2009,theAmericanSocietyofAnesrtKsiologists.Inc.LippincottWilliams&VGoal-directedColloidAdministrationImprovestheMicrocirculationofHealthyandPerianastomoticColonOliverKimberger,M.D.；MichaelArnberger,M.D.,*SebastianBrandt,M.D.；JanPlock,GisliH.Sigurdsson,M.D.,Ph.D/AndreaKurz,/W.D.,LuziusHil