液体复苏胶体的地位课件

液体复苏------胶体的地位中山大学附属第一医院重症医学科管向东液体复苏------胶体的地位中山大学附属第一医院---170多年前（1832年），一位苏格兰医师，发现了这种通过静脉血管把药液送入人体的治疗手段……---170多年前（1832年），明胶GELATIN白蛋白ALBUMIN1915WorldWarI1945WorldWarII1960’WarInVietnam右旋糖苷DEXTRAN羟乙基淀粉1943WorldWarII为什么要开发出这些胶体?明胶白蛋白191519451960’右旋糖苷羟乙基淀粉194重症液体复苏的重要性胶体及其作用目前的争论总结重症液体复苏的重要性什么是胶体?胶体（colloid）又称胶状分散体（colloidaldispersion）是一种均匀混合物，在胶体中含有两种不同相态的物质，一种分散，另一种连续。分散的一部分是由微小的粒子或液滴所组成，大小介于1到100纳米之间，且几乎遍布在整个连续相态中。按分散剂的不同可分为：气溶胶(雾、烟、云)；固溶胶(水晶、有色玻璃)液溶胶（蛋白溶液，淀粉溶液，肥皂水，人体血液）什么是胶体?胶体（colloid）又称胶状分散体（collo人体白蛋白的含量与分布细胞内液细胞外液体液-约占人体体重60%40%组织间液15%血浆5%蛋白质在血浆中含量远远高于组织间液血浆总蛋白含量约为60-80g/L其中，白蛋白含量约为35-50g/L（占血浆总蛋白的60%)人体白蛋白的含量与分布细胞细胞外液体液40%组织间液血浆5%2022/12/16Frank-Starling定律2022/12/12Frank-Starling定律(Multi-)OrganFailureCelldystructionbyimbalancebetweenO2-supplyandO2-consumptionO2undersupportO2debtMacrocirculatorydysfunction

COMicrocirculatorydysfunction(Multi-)OrganFailureCelldysWhatelsebesidesvolumerestrictionandexpansion?FluidresuscitationTissueoxygenationCapillaryleakameliorationHemodynamicsClinicaloutocmeRiskofAnaphylaxisEffectoncoagulationEffectonRenalfunctionJean-LouisVincent,MaxHarryWeil,CritCareMed2006;34:1333–1337WhatelsebesidesvolumerestrIntroductionAcutelyillpatientsfrequentlyrequirefluidrepletion.HypovolemiaExternalloss:bleeding,gastrointestinal,urinarytracts,skinInternalloss:extravasationofblood,exudation/transudationoffluidsRelativeHypovolemia:increasesvenouscapacitanceSepsis,drugsVolumerepletionmaybeessentialtorestorecriticallevelsofcardiacoutputandarterialpressure,resultinginmorenormalperfusionofvitalorgansandtissues.Jean-LouisVincent,MaxHarryWeil,CritCareMed2006;34:1333–1337IntroductionAcutelyillpatienAcutelyillpatientsfrequentlyrequirefluidrepletionHypovolemia:externalloss&internallossRelativeHypovolemia:increasesvenouscapacitanceVolumerepletionmaybeessentialRestorecriticallevelsofcardiacoutputandarterialpressureMorenormalperfusionofvitalorgansandtissuesJean-LouisVincent,MaxHarryWeil,CritCareMed2006;34:1333–1337AcutelyillpatientsfrequentlIntroductionHemorrhage:Benefit/riskoffluidrepletionmustbeassessedBenefitsofdelayedresuscitationLargevolumeoffluidredcelldeficitoxygendeficitPersistenthypovolemiawillresultinMODSFluidrepletionistypicallymoreeffectiveduringhypovolemicstatesbutislesseffectiveinlaterstages.Jean-LouisVincent,MaxHarryWeil,CritCareMed2006;34:1333–1337IntroductionHemorrhage:Fluidr“fluidchallenge”Jean-LouisVincent,MaxHarryWeil,CritCareMed2006;34:1333–1337DistinguishedfromconventionalfluidadministrationUsuallytocriticalpatientswithcardiorespiratoryfailureThefluidchallengeisreservedforhemodynamicallyunstablepatientsandoffersthreemajoradvantages:Quantitationofthecardiovascularresponseduringvolumeinfusion.Promptcorrectionoffluiddeficits.Minimizingtheriskoffluidoverloadanditspotentiallyadverseeffects,especiallyonthelungs.“fluidchallenge”Jean-LouisVi重症液体复苏的重要性胶体及其作用目前的争论总结重症液体复苏的重要性复苏液体种类白蛋白血浆?明胶胶体液晶体液林格氏液生理盐水

右旋糖苷羟乙基淀粉改良明胶HES200/0.5HES130/0.4尿联明胶聚明胶肽天然胶体人工胶体高渗盐液7.5%盐水+低右复苏液体种类白蛋白明胶胶体液晶体液林格氏液右旋糖苷羟乙基淀晶体液复苏？赞成使用晶体液的理由：费用低，容易得到对肾功能保持较好很少产生不良反应。这几种液体都能纠正脱水可纠正低钠血症高渗盐水（HS）扩容效率高反对使用晶体液的理由：平均留驻时间短（只有45min）液体输入量大造成血清白蛋白的稀释，血渗透压降低，间质水肿、肺水肿稀释血中凝血因子降低血小板计数和血红细胞压积血液携氧能力下降，降低组织氧合KoustovaE,StantonK,GushchinV,etal.Trauma2002;52:872-878.RotsteinOD.Trauma2000;49:580-83.LangK,BoldtJ,SuttnerS,etal.

Analg.2001.93:405-409.晶体液复苏？赞成使用晶体液的理由：KoustovaE,STheedemaproblemofcrystalloidsiswellknown“Fluidispouredintotheinterstitialspaceonclinicalinformationgainedfromchangesinintravascularspace….…Theend

point,….peripheralorpulmonaryedema”Twigley&Hillman,Anesthesia1985;40:860-871Theedemaproblemofcrystallo因生存率下降

NHLBI终止高张盐水治疗休克的研究NIH所属的国立心肺血液研究所(NHLBI)已经终止了一项有关严重出血导致休克的创伤患者的临床液体复苏干预试验该试验旨在研究高张盐水溶液治疗此类患者疗效及安全性试验终止的原因：观察到高张盐水治疗组患者在到达医院或急诊科前病死率显著升高，尽管高张盐水组及生理盐水组患者28天病死率（研究终点）相似

NHLBIHaltsStudyofConcentratedSalineforShockDuetoLackofSurvivalBenefit.AmericanAcademyofEmergencyMedicine

2009-16(3),

MedScapeToday

因生存率下降

NHLBI终止高张盐水治疗休克的研究NIH所液体复苏胶体的地位课件COPbalanceessentialforbalancedflowacrosscapillary

胶体渗透压的平衡是毛细血管的交换的基本因素CrystalloidscannotimpactCOP→Edema

单独使用晶体无法维持胶体渗透压→水肿ColloidshelptorestoreCOPandreduceCrystalloidload胶体液有助于恢复胶体渗透压和减少晶体负荷COPbalanceessentialforbala

Artery

(Arteriole)动脉,小动脉Vein

(Venule)静脉,小静脉PlasmaProtein

ColloidOsmoticPressure胶体渗透压22mmHg简化Starling定律HydrostaticPressure静水压32mmHgHydrostaticPressure静水压12mmHgTissueFluid组织液HypovolemiaEdema,organdamage低血容量水肿,器官损伤胶体渗透压Artery(Arteriole)Vein(Venu胶体液的作用容量作用：维持血流动力学稳定维持血浆胶体渗透压改善微循环／改善组织细胞氧供

非容量作用：改善CLS改善炎性反应物质结合和转运抗氧化作用……胶体液的作用容量作用：(colloid)151consecutively

majortraumapatientsWilliamC.Shoemaker

OutcomePredictionofEmergencyPatientsbyNoninvasiveHemodynamicMonitoringChest.2001;120:528-537(colloid)151consecutively

majWilliamC.Shoemaker

OutcomePredictionofEmergencyPatientsbyNoninvasiveHemodynamicMonitoringChest.2001;120:528-537Hemodynamcs（crystalloid）:151consecutively

majortraumapatientsWilliamC.ShoemakerOutcomePNormalSubstanceP-1minlaterStudyofCapillaryLeakDirect:ScanningEM:normalendothelialcelljunctionDonaldMcDonald1999NormalSubstanceP-1minlaterCrit

CareMed2006;34:1775–1782CritCareMed2006;34:1775–17白蛋白增加血浆中抗氧化剂硫醇含量GregoryJ.etc.CritCareMed.2004;32:755-759

白蛋白增加血浆中抗氧化剂硫醇含量GregoryJ.etc白蛋白增加血浆中抗氧化剂含量GregoryJ.etc.CritCareMed.2004;32:755-759

白蛋白增加血浆中抗氧化剂含量GregoryJ.etc.TheSAFEStudy

Alb:salinedeaths726:729(RR0.99)SimilarneworganfailuresICULOSHospitalLOSVentilatordurationRRTConclusion:OutcomewithalbumininICUnodifferentfromSalineQ:Doesthismeancrystalloidsandcolloidsarethesame?Doesthismeanallcolloidsaresame?Finferetal,NEJM2004;350:2247-56TheSAFEStudy

Alb:salinede重症液体复苏的重要性胶体及其作用目前的讨论总结重症液体复苏的重要性胶体液复苏并无优势------荟萃分析Objective:theeffectonmortalityofresuscitationwithcolloidcomparedwithcrystalloids.Design:Systematicreviewofrandomisedcontrolledtrialsofresuscitationwithcolloidscomparedwithcrystalloidsforcriticallyillpatients;Subjects:

37randomisedcontrolledtrialswereeligible:

26uncompoundedtrialsthatcomparedcolloidswithcrystalloids(n=1622),

10trialsthatcomparedcolloidinhypertoniccrystalloidwithisotoniccrystalloid(n=1422)

andonetrialthatcomparedcolloidinisotoniccrystalloidwithhypertoniccrystalloid(n=38).SchierhoutG,RobertsI.Fluidresuscitationwithcolloidor

crystalloidsolutionsincriticallyillpatients:asystematic

reviewofrandomisedtrials.BMJ

1998;316:961­4.Conclusions:Thissystematicreviewdoesnotsupportthecontinueduseofcolloidsforvolumereplacementincriticallyillpatients.胶体液复苏并无优势------荟萃分析Objective:Cochrane

Report（2008）ObjectivesToassesstheeffectsofcolloidscomparedtocrystalloidsforfluidresuscitationincriticallyillpatients.Mainresults:identified63eligibletrials,55ofthesepresentedmortalitydata.Colloidscomparedtocrystalloids•Albumin-23trialsreporteddataonmortality,includingatotalof7,754patients.Thepooledrelative

risk(RR)was1.01(95%confidenceinterval[95%CI]0.92to1.10).Whenthetrialwithpoorqualityallocation

concealmentwasexcluded,pooledRRwas1.00(95%CI0.91to1.09).•Hydroxyethylstarch-16trialscomparedhydroxyethylstarchwithcrystalloids,n=637patients.ThepooledRRwas1.05(95%

CI0.63to1.75).•Modifiedgelatin-11trialscomparedmodifiedgelatinwithcrystalloid,n=506patients.ThepooledRRwas0.91(95%CI0.49to1.72).•Dextran-ninetrialscompareddextranwithacrystalloid,n=834patients.ThepooledRRwas1.24(95%CI0.94to1.65).•Eighttrialscompareddextraninhypertoniccrystalloidwithisotoniccrystalloid,including1,283randomisedparticipants.Pooled

RRwas0.88(95%CI0.74to1.05).PerelP,RobertsI,Colloidsversuscrystalloidsforfluidresuscitationincriticallyillpatients(Review).TheCochraneLibrary2008,Issue3Authors’conclusions：ThereisnoevidencefromRCTsthatresuscitationwithcolloidsreducestheriskofdeath,comparedtoresuscitationwithcrystalloids,

inpatientswith

trauma,burnsorfollowingsurgery.CochraneReport（2008）ObjectiveCochrane

Report（2008）Ascolloidsarenotassociatedwithanimprovementinsurvival,andastheyare

moreexpensivethancrystalloids,itishardtoseehowtheircontinueduseinthesepatientscanbejustifiedoutsidethecontextofRCTs.PerelP,RobertsI,Colloidsversuscrystalloidsforfluidresuscitationincriticallyillpatients(Review).TheCochraneLibrary2008,Issue3注：Cochrane是国际最大的循证医学试验的协作网，以已故英国内科医师和著名流行病学家Archie

Cochrane的名字命名CochraneReport（2008）PerelP,胶体，ICU用，还是不用？胶体，ICU用，还是不用？FluidChallenge

500-100mlcristalloids300-500mlcolloidsover30mincontrolCVPorPAOPandreducespeed/volumeaccordingly

Grade1DSurvivingSepsisCampaign:Internationalguidelinesfor

managementofseveresepsisandsepticshock:2008CritCareMed2008Vol.36,No.1FluidChallenge500-100mlcriFigure.Differences(inpercentagefrombaseline)oftissueoxygentension(ptio2)inthetwovolumegroupsKatrinLang,JoachimBoldt,StefanSuttner,etal.

ColloidsVersusCrystalloidsandTissueOxygenTensioninPatientsUndergoingMajorAbdominalSurgery.AnesthAnalg2001;93:405–9Figure.Differences(inpercen白蛋白对于重症患者结论：白蛋白可以显著降低重症病例整体并发症的发生（危险比:0.92;可信区间:0.86-0.98)；且并发症的发生率与白蛋白的使用剂量显著相关（p=0.002)(Albumin-B-004)Vincent,Jean-Louis,Navickis,RobertaJ.Wilkes,MahlonM.

Morbidityinhospitalizedpatientsreceivinghumanalbumin:Ameta-analysisofrandomized,controlledtrials*

CritCareMed2004;32(10):2029-2038白蛋白对于重症患者结论：白蛋白可以显著降低重症病例整体并发症胶体：我们关心的组织氧代谢？SHOCK,2006

Vol.25,No.2,pp.103Y116胶体：我们关心的组织氧代谢？SHOCK,2006Vol SchortgenetcollLancet2001,357,911SurvivorsHEAorgelatineforSevereSepsis?SurvivorsHEAorgelatineforSResuscitation:selectionofFluidCrystalloidsorColloidscanbeusedFluidchallengeswithcolloidsallowformorerapidcompletionofchallenge.Crystalloid:Physiologic(0.9%)saltsolution(saline)MayincreaseserumchlorideconcentrationsBalancedsaltsolutions(Ringer’slactate/Hartmann’ssolution)Mildlyhypotonic,mayexacerbatecerebraledemaJean-LouisVincent,MaxHarryWeil,CritCareMed2006;34:1333–1337Resuscitation:selectionofFluResuscitation:selectionofFluidSAFEstudy:albuminvscrystalloidsolutionMortalityratewasidenticalHypoalbuminemiaisassociatedwithhighermorbidityVincentJLetal,AnnSurg2003;237:319–334:meta-analysisAlbuminadministrationmayreducecomplicationsincriticallyillpatientsSAFEtrial:Improvedsurvivalwithalbumininpatientswithsepsiswhoarehypoalbuminemia(relativeriskofdeath,0.87;95%CI,0.74–1.02;p0.06)AlbuminmaybebeneficialinthissubsetofcriticallyillpatientsJean-LouisVincent,MaxHarryWeil,CritCareMed2006;34:1333–1337Resuscitation:selectionofFlResuscitation:selectionofFluidSyntheticcolloidsolution:Hydroxyethylstarchsolutions:Lessexpensive,adverseeffectsonbloodclottingGelatins:SmallerMW,lesseffectiveplasmaexpanders,lowcostJean-LouisVincent,MaxHarryWeil,CritCareMed2006;34:1333–1337Resuscitation:selectionofFlResuscitation:selectionofFluidNointravenousfluidsolutionthatisidealinallclinicalsettingsNosecuredatasupportapreferenceforoneoveranotherThechoiceisbestmadecontingenton:theunderlyingdiseasethetypeoffluidthathasbeenlosttheseverityofcirculatoryfailuretheserumalbuminconcentrationofthepatienttheriskofbleeding.Jean-LouisVincent,MaxHarryWeil,CritCareMed2006;34:1333–1337Resuscitation:selectionofFl重症液体复苏的重要性胶体及其作用目前的争论总结重症液体复苏的重要性总结重症病人的液体复苏，是最重要/最早的复苏手段之一容量替代、血流动力学稳定、组织氧合均是临床液体复苏的重要目标液体选择种类很多，无论何种液体（晶胶体），从使用开始，需要考虑不良作用胶体液的使用，要同时考虑容量以外问题目前，晶体或胶体复苏孰优孰劣，需要更有说服力的循证医学证据支持总结重症病人的液体复苏，是最重要/最早的复苏手段之一谢谢！谢谢！液体复苏------胶体的地位中山大学附属第一医院重症医学科管向东液体复苏------胶体的地位中山大学附属第一医院---170多年前（1832年），一位苏格兰医师，发现了这种通过静脉血管把药液送入人体的治疗手段……---170多年前（1832年），明胶GELATIN白蛋白ALBUMIN1915WorldWarI1945WorldWarII1960’WarInVietnam右旋糖苷DEXTRAN羟乙基淀粉1943WorldWarII为什么要开发出这些胶体?明胶白蛋白191519451960’右旋糖苷羟乙基淀粉194重症液体复苏的重要性胶体及其作用目前的争论总结重症液体复苏的重要性什么是胶体?胶体（colloid）又称胶状分散体（colloidaldispersion）是一种均匀混合物，在胶体中含有两种不同相态的物质，一种分散，另一种连续。分散的一部分是由微小的粒子或液滴所组成，大小介于1到100纳米之间，且几乎遍布在整个连续相态中。按分散剂的不同可分为：气溶胶(雾、烟、云)；固溶胶(水晶、有色玻璃)液溶胶（蛋白溶液，淀粉溶液，肥皂水，人体血液）什么是胶体?胶体（colloid）又称胶状分散体（collo人体白蛋白的含量与分布细胞内液细胞外液体液-约占人体体重60%40%组织间液15%血浆5%蛋白质在血浆中含量远远高于组织间液血浆总蛋白含量约为60-80g/L其中，白蛋白含量约为35-50g/L（占血浆总蛋白的60%)人体白蛋白的含量与分布细胞细胞外液体液40%组织间液血浆5%2022/12/16Frank-Starling定律2022/12/12Frank-Starling定律(Multi-)OrganFailureCelldystructionbyimbalancebetweenO2-supplyandO2-consumptionO2undersupportO2debtMacrocirculatorydysfunction

COMicrocirculatorydysfunction(Multi-)OrganFailureCelldysWhatelsebesidesvolumerestrictionandexpansion?FluidresuscitationTissueoxygenationCapillaryleakameliorationHemodynamicsClinicaloutocmeRiskofAnaphylaxisEffectoncoagulationEffectonRenalfunctionJean-LouisVincent,MaxHarryWeil,CritCareMed2006;34:1333–1337WhatelsebesidesvolumerestrIntroductionAcutelyillpatientsfrequentlyrequirefluidrepletion.HypovolemiaExternalloss:bleeding,gastrointestinal,urinarytracts,skinInternalloss:extravasationofblood,exudation/transudationoffluidsRelativeHypovolemia:increasesvenouscapacitanceSepsis,drugsVolumerepletionmaybeessentialtorestorecriticallevelsofcardiacoutputandarterialpressure,resultinginmorenormalperfusionofvitalorgansandtissues.Jean-LouisVincent,MaxHarryWeil,CritCareMed2006;34:1333–1337IntroductionAcutelyillpatienAcutelyillpatientsfrequentlyrequirefluidrepletionHypovolemia:externalloss&internallossRelativeHypovolemia:increasesvenouscapacitanceVolumerepletionmaybeessentialRestorecriticallevelsofcardiacoutputandarterialpressureMorenormalperfusionofvitalorgansandtissuesJean-LouisVincent,MaxHarryWeil,CritCareMed2006;34:1333–1337AcutelyillpatientsfrequentlIntroductionHemorrhage:Benefit/riskoffluidrepletionmustbeassessedBenefitsofdelayedresuscitationLargevolumeoffluidredcelldeficitoxygendeficitPersistenthypovolemiawillresultinMODSFluidrepletionistypicallymoreeffectiveduringhypovolemicstatesbutislesseffectiveinlaterstages.Jean-LouisVincent,MaxHarryWeil,CritCareMed2006;34:1333–1337IntroductionHemorrhage:Fluidr“fluidchallenge”Jean-LouisVincent,MaxHarryWeil,CritCareMed2006;34:1333–1337DistinguishedfromconventionalfluidadministrationUsuallytocriticalpatientswithcardiorespiratoryfailureThefluidchallengeisreservedforhemodynamicallyunstablepatientsandoffersthreemajoradvantages:Quantitationofthecardiovascularresponseduringvolumeinfusion.Promptcorrectionoffluiddeficits.Minimizingtheriskoffluidoverloadanditspotentiallyadverseeffects,especiallyonthelungs.“fluidchallenge”Jean-LouisVi重症液体复苏的重要性胶体及其作用目前的争论总结重症液体复苏的重要性复苏液体种类白蛋白血浆?明胶胶体液晶体液林格氏液生理盐水

右旋糖苷羟乙基淀粉改良明胶HES200/0.5HES130/0.4尿联明胶聚明胶肽天然胶体人工胶体高渗盐液7.5%盐水+低右复苏液体种类白蛋白明胶胶体液晶体液林格氏液右旋糖苷羟乙基淀晶体液复苏？赞成使用晶体液的理由：费用低，容易得到对肾功能保持较好很少产生不良反应。这几种液体都能纠正脱水可纠正低钠血症高渗盐水（HS）扩容效率高反对使用晶体液的理由：平均留驻时间短（只有45min）液体输入量大造成血清白蛋白的稀释，血渗透压降低，间质水肿、肺水肿稀释血中凝血因子降低血小板计数和血红细胞压积血液携氧能力下降，降低组织氧合KoustovaE,StantonK,GushchinV,etal.Trauma2002;52:872-878.RotsteinOD.Trauma2000;49:580-83.LangK,BoldtJ,SuttnerS,etal.

Analg.2001.93:405-409.晶体液复苏？赞成使用晶体液的理由：KoustovaE,STheedemaproblemofcrystalloidsiswellknown“Fluidispouredintotheinterstitialspaceonclinicalinformationgainedfromchangesinintravascularspace….…Theend

point,….peripheralorpulmonaryedema”Twigley&Hillman,Anesthesia1985;40:860-871Theedemaproblemofcrystallo因生存率下降

NHLBI终止高张盐水治疗休克的研究NIH所属的国立心肺血液研究所(NHLBI)已经终止了一项有关严重出血导致休克的创伤患者的临床液体复苏干预试验该试验旨在研究高张盐水溶液治疗此类患者疗效及安全性试验终止的原因：观察到高张盐水治疗组患者在到达医院或急诊科前病死率显著升高，尽管高张盐水组及生理盐水组患者28天病死率（研究终点）相似

NHLBIHaltsStudyofConcentratedSalineforShockDuetoLackofSurvivalBenefit.AmericanAcademyofEmergencyMedicine

2009-16(3),

MedScapeToday

因生存率下降

NHLBI终止高张盐水治疗休克的研究NIH所液体复苏胶体的地位课件COPbalanceessentialforbalancedflowacrosscapillary

胶体渗透压的平衡是毛细血管的交换的基本因素CrystalloidscannotimpactCOP→Edema

单独使用晶体无法维持胶体渗透压→水肿ColloidshelptorestoreCOPandreduceCrystalloidload胶体液有助于恢复胶体渗透压和减少晶体负荷COPbalanceessentialforbala

Artery

(Arteriole)动脉,小动脉Vein

(Venule)静脉,小静脉PlasmaProtein

ColloidOsmoticPressure胶体渗透压22mmHg简化Starling定律HydrostaticPressure静水压32mmHgHydrostaticPressure静水压12mmHgTissueFluid组织液HypovolemiaEdema,organdamage低血容量水肿,器官损伤胶体渗透压Artery(Arteriole)Vein(Venu胶体液的作用容量作用：维持血流动力学稳定维持血浆胶体渗透压改善微循环／改善组织细胞氧供

非容量作用：改善CLS改善炎性反应物质结合和转运抗氧化作用……胶体液的作用容量作用：(colloid)151consecutively

majortraumapatientsWilliamC.Shoemaker

OutcomePredictionofEmergencyPatientsbyNoninvasiveHemodynamicMonitoringChest.2001;120:528-537(colloid)151consecutively

majWilliamC.Shoemaker

OutcomePredictionofEmergencyPatientsbyNoninvasiveHemodynamicMonitoringChest.2001;120:528-537Hemodynamcs（crystalloid）:151consecutively

majortraumapatientsWilliamC.ShoemakerOutcomePNormalSubstanceP-1minlaterStudyofCapillaryLeakDirect:ScanningEM:normalendothelialcelljunctionDonaldMcDonald1999NormalSubstanceP-1minlaterCrit

CareMed2006;34:1775–1782CritCareMed2006;34:1775–17白蛋白增加血浆中抗氧化剂硫醇含量GregoryJ.etc.CritCareMed.2004;32:755-759

白蛋白增加血浆中抗氧化剂硫醇含量GregoryJ.etc白蛋白增加血浆中抗氧化剂含量GregoryJ.etc.CritCareMed.2004;32:755-759

白蛋白增加血浆中抗氧化剂含量GregoryJ.etc.TheSAFEStudy

Alb:salinedeaths726:729(RR0.99)SimilarneworganfailuresICULOSHospitalLOSVentilatordurationRRTConclusion:OutcomewithalbumininICUnodifferentfromSalineQ:Doesthismeancrystalloidsandcolloidsarethesame?Doesthismeanallcolloidsaresame?Finferetal,NEJM2004;350:2247-56TheSAFEStudy

Alb:salinede重症液体复苏的重要性胶体及其作用目前的讨论总结重症液体复苏的重要性胶体液复苏并无优势------荟萃分析Objective:theeffectonmortalityofresuscitationwithcolloidcomparedwithcrystalloids.Design:Systematicreviewofrandomisedcontrolledtrialsofresuscitationwithcolloidscomparedwithcrystalloidsforcriticallyillpatients;Subjects:

37randomisedcontrolledtrialswereeligible:

26uncompoundedtrialsthatcomparedcolloidswithcrystalloids(n=1622),

10trialsthatcomparedcolloidinhypertoniccrystalloidwithisotoniccrystalloid(n=1422)

andonetrialthatcomparedcolloidinisotoniccrystalloidwithhypertoniccrystalloid(n=38).SchierhoutG,RobertsI.Fluidresuscitationwithcolloidor

crystalloidsolutionsincriticallyillpatients:asystematic

reviewofrandomisedtrials.BMJ

1998;316:961­4.Conclusions:Thissystematicreviewdoesnotsupportthecontinueduseofcolloidsforvolumereplacementincriticallyillpatients.胶体液复苏并无优势------荟萃分析Objective:Cochrane

Report（2008）ObjectivesToassesstheeffectsofcolloidscomparedtocrystalloidsforfluidresuscitationincriticallyillpatients.Mainresults:identified63eligibletrials,55ofthesepresentedmortalitydata.Colloidscomparedtocrystalloids•Albumin-23trialsreporteddataonmortality,includingatotalof7,754patients.Thepooledrelative

risk(RR)was1.01(95%confidenceinterval[95%CI]0.92to1.10).Whenthetrialwithpoorqualityallocation

concealmentwasexcluded,pooledRRwas1.00(95%CI0.91to1.09).•Hydroxyethylstarch-16trialscomparedhydroxyethylstarchwithcrystalloids,n=637patients.ThepooledRRwas1.05(95%

CI0.63to1.75).•Modifiedgelatin-11trialscomparedmodifiedgelatinwithcrystalloid,n=506patients.ThepooledRRwas0.91(95%CI0.49to1.72).•Dextran-ninetrialscompareddextranwithacrystalloid,n=834patients.ThepooledRRwas1.24(95%CI0.94to1.65).•Eighttrialscompareddextraninhypertoniccrystalloidwithisotoniccrystalloid,including1,283randomisedparticipants.Pooled

RRwas0.88(95%CI0.74to1.05).PerelP,RobertsI,Colloidsversuscrystalloidsforfluidresuscitationincriticallyillpatients(Review).TheCochraneLibrary2008,Issue3Authors’conclusions：ThereisnoevidencefromRCTsthatresuscitationwithcolloidsreducestheriskofdeath,comparedtoresuscitationwithcrystalloids,

inpatientswith

trauma,burnsorfollowingsurgery.CochraneReport（2008）ObjectiveCochrane

Report（2008）Ascolloidsarenotassociatedwithanimprovementinsurvival,andastheyare

moreexpensivethancrystalloids,itishardtoseehowtheircontinueduseinthesepatientscanbejustifiedoutsidethecontextofRCTs.PerelP,RobertsI,Colloidsversuscrystalloidsforfluidresuscitationincriticallyillpatients(Review).TheCochraneLibrary2008,Issue3注：Cochrane是国际最大的循证医学试验的协作网，以已故英国内科医师和著名流行病学家Archie

Cochrane的名字命名CochraneReport（2008）PerelP,胶体，ICU用，还是不用？胶体，ICU用，还是不用？FluidChallenge

500-100mlcristalloids300-500mlcolloidsover30mincontrolCVPorPAOPandreducespeed/volumeaccordingly

Grade1DSurvivingSepsisCampaign:Internationalguidelinesfor

managementofseveresepsisandsepticshock:2008CritCareMed2008Vol.36,No.1FluidChallenge500-100mlcriFigure.Differences(inpercentagefrombaseline)oftissueoxygentension(ptio2)inthetwovolumegroupsKatrinLang,JoachimBoldt,StefanSuttner,etal.

ColloidsVersusCrystalloidsandTissueOxygenTensioninPatientsUndergoingMajorAbdominalSurgery.AnesthAnalg2001;93:405–9Figure.Differences(inpercen白蛋白对于重症患者结论：白蛋白可以显著降低重症病例整体并发症的发生（危险比:0.92;可信区间:0.86-0.98)；且并发症的发生率与白蛋白的使用