麻醉专业培训英语课件-Fluid Management in Liver Transplantation

FluidManagementinLiverTransplantationIntraoperativeFluidManagementcorrectanypreexistingdeficitduetofastingandgastrointestinallosses.supplybasalneeds.replacebloodandotherlosses,andmaintainfluidandelectrolytehomeostasisTheGoaloftheFluidManagementintravascularfluidvolume,leftventricularfillingpressure,cardiacoutput,systemicbloodpressure,oxygendeliverytotissues.FactorsAffectingtheAmountof

IntraoperativeFluidAdministrationChest1999;115;106S-112SIntraoperativeFluidStrategiesFluidStrategiesFixed-volumefluidtherapyRestrictivefluidtherapyGoal-directedFluidtherapyMonitoringVariablesStatic:HR,ArterialBp,andCardiacfillingpressureDynamic:Strokevolume,PulsepressurevariationFixedVolumeFluidTherapyIntraoperativeFluidReplacementLiberal（high)vsRestrictive(low)ActaAnaesthesiolScand2009;53:843–851AseriesofStarlingventricularfunctioncurvesChest1999;115;106S-112SOptimalversusRestrictiveStrategyInternatAnesthesiolClinic2010;48(1):115–125ProposedRelationshipbetweenFluidBalanceGlassfordNJ,MylesP,andBellomoR:CurrOpinAnesthesiol2012;25:102-110DynamicMonitoringPerioperativeFluidActaAnaesthesiolScand2007;51:331–340HadassahHebrewUniversityMedicalCenter.152patientswithanAmericanSocietyofAnesthesiologistsphysicalstatusofI–IIIwhowereundergoingelectiveintraabdominalsurgery.randomlyassignedtoreceiveintraoperativelyeither(75patients)liberal(liberalprotocolgroup[LPG],bolusof10ml/kgfollowedby12ml/kg/hor(77patients)restrictive(restrictiveprotocolgroup[RPG];4ml/kg/hamountsoflactatedRinger’ssolution.Theprimaryendpointwasthenumberofpatientswhodiedorexperiencedcomplications.Thesecondaryendpointsincludedtimetoinitialpassageofflatusandfeces,durationofhospitalstay,andchangesinbodyweight,hematocrit,andalbuminserumconcentrationinthefirst3postoperativedays.PerioperativeComplicationsAnesthesiology2005;103:25–32bodyweightintheLPGcomparedwithpatientsintheRPGintheearlypostoperativeperiod(1.93+/-0.52and1.85+/-0.62kgonthefirstandthirdpostoperativedays,respectively,intheLPGvs.0.51+/-0.67and0.24+/-0.61kgintheRPG;P<0.01).passedflatusandfecesintheLPGsignificantlylaterthanRPGpatients(flatus,median[range]:4[3–7]daysintheLPGvs.3[2–7]daysintheRPG;P<0.001;feces:6[4–9]daysintheLPGvs.4[3–9]daysintheRPG;P<0.001).Thedurationofhospitalstaywas9days(7–24)intheLPGcomparedwith8days(6–21)intheRPG(P=0.01).EffectofLiberalvsRestrictiveFluidAdministrationonNightlyPostoperativeHypoxaemiaafterColonicSurgeryHighv.sLowFluid48ASAI–IIpatientsundergoinglaparoscopiccholecystectomy15mL/kgor40mL/kgoflactatedRinger’ssolutionintraoperativelythehigherdoseoffluidwasassociatedwithimprovedostoperativepulmonaryfunctionandexercisecapacity,reducedeurohumoralstressresponse,andimprovementsinnauseaAnnSurg2004;240:892–9LactateRinger’sv.sNormalSalineAnesthesiology1999;90:1265–70Gynpatientsreceived60ml/kg/hfortwohoursCommonlyusedHydroxyethylstarches

Importantphysicochemicalcharacteristics

JoachimBoldtandColloid

AccordingtotheISIWebofSciencedatabase,85of346publicationsauthoredbyDr.Boldtdealwithintravascularvolumetherapy.Ofthese,30studiesand2reviewswereincludedinrecentmeta-analysesandconsensusguidelinesBecauseoftheshadowcastonDr.Boldt’spublicationsbytherecentretraction,weneedtoaskwhatevidenceonthesafetyandefficacyofHESremainsifhispublicationswerenottakenintoaccount.HES130/0.4（Voluven™)hasrapidlybecomeawidelyusedIVsolution.Thereare56randomizedcontrolledtrials(RCTs)onHES130/0.4.21One-thirdoftheseRCTswerepublishedbyBoldtetal.,allintheelectivesurgicalsetting.Theremaining28surgicalRCTshavelowpower(medianpatientsn27inHESvsn33incontrolgroups)andpublishedclinicaldataareinadequatetosupporttheconclusionthatHES130/0.4issaferthanotherHESsolutionsinsurgicalandcriticallyillpatients.Scientificmisconductisdifficulttoprevent.Thebestpreventivemeasureisofappropriatelydesignedandpoweredclinicaltrialstoprovidedefinitiveevidenceofsafetyandefficacy.Thegrayareabetween“simple”infusionfluidsandpharmacologicproductssuchassyntheticcolloidsshouldbebetterdefined.Trialsareunderway:theCHESTtrialbytheANZICSclinicaltrialsgroup(c:NCT00935168);theScandinavian6Ssepsistrial(:NCT00962156)ANESTHESIA&ANALGESIAMarch2011•Volume112•Number3Livertransplantationisan

extensivebloodyoperation.Dr.YoogooKangLiverTransplant:ThreeStagesBloodTransfusionandPerioperativeMortalityAnesthesiology1999;91(1):329-330BloodTransfusionandOutcomesLiverTransplantation2003;9(2):1320-1327About300livertransplantpatientsWithhistoricalcontrol9anesthesiologistsTriggeringtransfusionwasHb,6.8LoweringCVP40%ofbaselineduringstageIby-restrictingfluidor-phlebotomywithoutvolumereplacementor-combinedNote:phlebotomystoppedifBpdecreasedmorethan20%ofbaseline.ComparisonofTwoGroups(1998-2002,2002-2003)AccordingtotheVariablesThatCouldInfluencetheBloodLossorRBCTransfusionRate

BloodLossorRBCTransfusionRateMassicotteLetal:LiverTransplantation2006;12:117-123FluidManagementTheThirdSpaceDilemmaBestPracResClinAnaest23(2009)145–157MultidisciplinaryICUsof16academictertiaryhospitalsinAustraliaandNewZealandNovember2001andJune20036997(7000)patientsrandomassignmentstoastudytreatment,3499toalbumingroupand3501tosalinegroup.Followedfor28daysEligiblepatientswererandomlyassignedtoreceiveeither4percentalbumin(Albumex,CSL)ornormalsaline(blindtousers)NEnglJMed2004;350:2247-56SafeStudy-continueVolumeofinfusionrequiredtoexpandtheplasmavolumeby1LLoboDN:thedoctoraldissertation,UnivNottingham2002LoboDN:thedoctoraldissertation,UnivNottingham2002AlbuminforHypoalbuminemiaAnnSurg2003;237:319-334OtherColloids,HydroxyethylStarch?

ItiswellrecognizedintheU.S.AlbuminisdominantlyusedforlivertransplantControversialresultsareconcernedforenzymaticmetabolismandcoagulationdisturbances.Dr.Boldt’sshadow.Newdataareemergent.NormalSalineandLactatedRinger’s(AnesthAnalg2008;107:264–9)-Turkey-90livingrelatedkidneyrecipientsMonitoringFluidManagementTherelationfoCVPandBloodVolumeROCcurveanddiagnostictestaccuracyCritCareMed1984;12:107–112AUC>0.8AUC0.6-0.7AUC</=0.5Chest2008;134: