感染性休克的液体复苏课件

1、感染性休克的液体复苏感染性休克的液体复苏补什么?补多少?补多快?Fluid resuscitation of septic shock2001 EGDT2004 initial guidelines2008 updated version guidelines2010 severe sepsis bundlesFluid resuscitation of septic shock2001 EGDT2004 initial guidelines2008 updated version guidelines2010 severe sepsis bundles2012 updated Guideli

2、nesEmanuel Rivers et al.N Engl J Med 2001;345:1368-77In-hospital mortality was 30.5 percent in the group assigned to early goal-directed therapy, as compared with 46.5 percent in the group assigned to standard therapy (P=0.009).Emanuel Rivers et al.N Engl J Med 2001;345:1368-77Emanuel Rivers et al.N

3、 Engl J Med 2001;345:1368-77R. Phillip Dellinger et al. Crit Care Med. 2008;36(1):296-327.Fluid therapyFluid-resuscitate using crystalloids or colloids. （1B ）Target a CVP of 8mmHg （ 12mmHg if mechanically ventilated ）. （ 1C ）Use a fluid challenge technique while associated with a haemodynamic improv

4、ement. （ 1D ）R. Phillip Dellinger et al. Crit Care Med. 2008;36(1):296-327.Fluid therapyGive fluid challenges of 1000 ml of crystalloids or 300500 ml of colloids over 30min. More rapid and larger volumes may be required in sepsis-induced tissue hypoperfusion. （ 1D ）Rate of fluid administration shoul

5、d be reduced if cardiac filling pressures increase without concurrent hemodynamic improvement. （ 1D ）R. Phillip Dellinger et al. Crit Care Med. 2008;36(1):296-327.Sepsis Resuscitation Bundle（first 6hrs）1. Serum lactate measured.2. Blood cultures obtained prior to antibiotic administration.3. From th

6、e time of presentation, broad-spectrum antibiotics administered within 3 hours for ED admissions and 1 hour for non-ED ICU admissions.Levy MM et al. Intensive Care Med. 2010;36(2):222-31.Sepsis Resuscitation Bundle（first 6hrs）4. In the event of hypotension and/or lactate 4 mmol/L (36 mg/dl): a) Deli

7、ver an initial minimum of 20 ml/kg of crystalloid (or colloid equivalent).b) Apply vasopressors for hypotension not responding to initial fluid resuscitation to maintain mean arterial pressure (MAP) 65 mm Hg.Levy MM et al. Intensive Care Med. 2010;36(2):222-31.1. Low-dose steroids administered for s

8、eptic shock in accordance with a standardized hospital policy.2. Drotrecogin alfa (activated) administered in accordance with a standardized hospital policy.Sepsis Management Bundle（first 24hrs） Levy MM et al. Intensive Care Med. 2010;36(2):222-31.3. Glucose control maintained lower limit of normal,

9、 but 150 mg/dl (8.3 mmol/L).4. Inspiratory plateau pressures maintained 30 cm H2O for mechanically ventilated patients.Sepsis Management Bundle（first 24hrs） Levy MM et al. Intensive Care Med. 2010;36(2):222-31.Main resultsData from 15,022 subjects at 165 sites were analyzed to determine the complian

10、ce with bundle targets and association with hospital mortality. Levy MM et al. Intensive Care Med. 2010;36(2):222-31.Main resultsCompliance with the entire resuscitation bundle increased linearly from 10.9% in the first site quarter to 31.3% by the end of 2 years (P 0.4 in patients with severe sepsi

11、s or risk of acute kidney injury and suggest not to use 6% HES 130/0.4 or gelatin in these populations.Reinhart K et al. Intensive Care Med. 2012;38(3):368-83.Recommendations and conclusionsWe recommend not to use colloids in patients with head injury and not to administer gelatins and HES in organ

12、donors. Reinhart K et al. Intensive Care Med. 2012;38(3):368-83.Recommendations and conclusionsWe suggest not to use hyperoncotic solutions for fluid resuscitation. Until the results of the ongoing studies (ESM) become available and in the absence of other RCTs comparing the use of hyperoncotic albu

13、min with other fluid for shock resuscitation, the safety of hyperoncotic albumin remains unclear for the correction of hypoalbuminaemia and for resuscitation in shock.Reinhart K et al. Intensive Care Med. 2012;38(3):368-83.Recommendations and conclusionsWe conclude and recommend that any new colloid

14、 should be introduced into clinical practice only after its patient-important safety parameters are establishedReinhart K et al. Intensive Care Med. 2012;38(3):368-83.Brochard L et al. Am J Respir Crit Care Med.2010 ;181(10):1128-55.Panel recommendationsWe consider fluid resuscitation with crystallo

15、ids to be as effective and safe as fluid resuscitation with hypooncotic colloids (gelatins and 4% albumin).Based on current knowledge, we recommend that hyperoncotic solutions (dextrans, hydroxyethylstarches, or 20-25% albumin) not be used for routine fluid resuscitation because they carry a risk fo

16、r renal dysfunction.Brochard L et al. Am J Respir Crit Care Med.2010 ;181(10):1128-55.Decreased glomerular filtration pressure due to increased intracapillary oncotic pressure and (direct) colloid nephrotoxicity (osmotic nephrosis) are the two purported mechanisms responsible for the higher incidenc

17、e of renal dysfunction with hyperoncotic colloids than with crystalloids or hypooncotic colloids . Brochard L et al. Am J Respir Crit Care Med.2010 ;181(10):1128-55.In addition, many adverse effects have been described using synthetic colloids . These include anaphylactic and anaphylactoid reactions

18、, blood coagulation disorders, and, in the case of starches, also liver failure and pruritus.Brochard L et al. Am J Respir Crit Care Med.2010 ;181(10):1128-55.补多少？& 补多快？Resuscitation goals: (1C)CVP 8-12 mmHg(A higher target CVP of 12-15 mmHg is recommended in the presence of mechanical ventilation o

19、r pre-existing decreased ventricular compliance.)MAP65 mm HgUrine output 0.5 mL.kg-1.hr-1Central venous (superior vena cava) oxygen saturation 70%, or mixed venous 65%R. Phillip Dellinger et al. Crit Care Med. 2008;36(1):296-327.CVP 8-12mmHg?Frank-Starling Curve心室P-V曲线Marik PE et al.Ann Intensive Ca

20、re. 2011;1(1):1.Marik PE et al.Ann Intensive Care. 2011;1(1):1.Does Central Venous Pressure PredictFluid Responsiveness?Marik PE et al.Chest. 2008;134(1):172-8.Conclusions: This systematic review demonstrated a very poor relationship between CVP and blood volume as well as the inability of CVP/CVP t

21、o predict the hemodynamic response to a fluid challenge. CVP should not be used to make clinical decisions regarding fluid management.Marik PE et al.Chest. 2008;134(1):172-8.DiscussionIn other words, our results suggest that at any CVP the likelihood that CVP can accurately predict fluid responsiven

22、ess is only 56% (no better than flipping a coin).Furthermore, an AUC of 0.56 suggests that there is no clear cutoff point that helps the physician to determine if the patient is “wet” or “dry”.Marik PE et al.Chest. 2008;134(1):172-8.DiscussionIt is important to emphasize that a patient is equally li

23、kely to be fluid responsive with a low or a high CVP. The results from this study therefore confirm that neither a high CVP, a normal CVP, a low CVP, nor the response of the CVP to fluid loading should be used in the fluid management strategy of any patient.Marik PE et al.Chest. 2008;134(1):172-8.Di

24、scussionIt should also be recognized that CVP was a component of early goal-directed therapy in the landmark article by Rivers and colleagues. However, both the control and intervention groups had CVP targeted to 8 to 12mm Hg. Marik PE et al.Chest. 2008;134(1):172-8.DiscussionBased largely on the re

25、sults of the early goal-directed therapy study, the Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock recommend a CVP of 8 to 12mmHg as the “goal of the initial resuscitation of sepsis-induced hypoperfusion” and “a higher targeted central venous pressure of 1215 m

26、mHg” in patients receiving mechanical ventilation. Marik PE et al.Chest. 2008;134(1):172-8.DiscussionThe results of our study suggest that these recommendations should be revisited.Marik PE et al.Chest. 2008;134(1):172-8.MAP65 mmHg?Emanuel Rivers et al.N Engl J Med 2001;345:1368-77 tonometry PCO2 ga

27、pred cell velocitycapillaryflowurineoutput1501005013%*NE dosecardiac indexSVlactate3.14.7998*LeDoux D et al.Crit Care Med. 2000;28(8):2729-32.Mean arterial pressureOrganBloodflowmmHg65Mean arterial pressureOrganBloodflowmmHgno prior hypertensionwith prior hypertension65Strandgaard S et

28、al.Br Med J.1973;1(5852):507-10Urine output 0.5 mL.kg-1.hr-1?ScvO2 70%?Variable and Treatment groupBase Line0 hrCVP mmHg Standard therapy 6 8 EGDT 5 9MAP mmHg Standard therapy 76 24 EGDT 74 276 hrs after the start of therapyTotal fluids (mL) Any vasopressor (%) 12 714 43499 24384981 298481 1895 1966

29、 1677 1030.327.4Emanuel Rivers et al.N Engl J Med 2001;345:1368-77其他指标?Lactate clearancePassive leg raisingPPVDynamic measures of echocardiographic functionLactate clearance? the researchers suggest that in the initial resuscitation phase of severe sepsis and septic shock, patients with elevated lac

30、tate levelsa marker of tissue hypoperfusionshould be normalized as quickly as possible in facilities that do not have the capability to target central venous oxygen saturation (weak recommendation; Grade 2C).Surviving Sepsis Campaign Previews Updated Guidelines for 2012Passive leg raising?Marik PE e

31、t al.Ann Intensive Care. 2011;1(1):1.Marik PE et al.Ann Intensive Care. 2011;1(1):1.Prau S et al.Crit Care Med. 2010;38(3):819-25.Conclusions: Changes in stroke volume, radial pulse pressure, and peak velocity of femoral artery flow induced by passive leg raising are accurate and interchangeable ind

32、ices for predicting fluid responsiveness in nonintubated patients with severe sepsis or acute pancreatitis.Prau S et al.Crit Care Med. 2010;38(3):819-25.Study name sample size AUC Monnet CCM 2006 71 0.96Lafanchre CC 2006 22 0.95Lamia ICM 2007 24 0.96Maizel ICM 2007 34 0.89Monnet CCM 2009 34 0.94Thiel