感染性休克的液体复苏

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?Fluidresuscitationofsepticshock2001EGDT2004initialguidelines2008updatedversionguidelines2010severesepsisbundlesFluidresuscitationofsepticshock2001EGDT2004initialguidelines2008updatedversionguidelines2010severesepsisbundles2012updatedGuidelinesEmanuelRiversetal.NEnglJMed2001;345:1368-77In-hospitalmortalitywas30.5percentinthegroupassignedtoearlygoal-directedtherapy,ascomparedwith46.5percentinthegroupassignedtostandardtherapy(P=0.009).EmanuelRiversetal.NEnglJMed2001;345:1368-77EmanuelRiversetal.NEnglJMed2001;345:1368-77EmanuelRiversetal.NEnglJMed2001;345:1368-77R.PhillipDellingeretal.CritCareMed.2008;36(1):296-327.R.PhillipDellingeretal.CritCareMed.2008;36(1):296-327.FluidtherapyFluid-resuscitateusingcrystalloidsorcolloids.（1B）TargetaCVPof≥8mmHg

（≥12mmHgifmechanicallyventilated

）.（1C）Useafluidchallengetechniquewhileassociatedwithahaemodynamicimprovement.（1D

）R.PhillipDellingeretal.CritCareMed.2008;36(1):296-327.FluidtherapyGivefluidchallengesof1000mlofcrystalloidsor300–500mlofcolloidsover30min.Morerapidandlargervolumesmayberequiredinsepsis-inducedtissuehypoperfusion.（1D）Rateoffluidadministrationshouldbereducedifcardiacfillingpressuresincreasewithoutconcurrenthemodynamicimprovement.（1D）R.PhillipDellingeretal.CritCareMed.2008;36(1):296-327.LevyMMetal.IntensiveCareMed.2010;36(2):222-31.SepsisResuscitationBundle（first6hrs）1.Serumlactatemeasured.2.Bloodculturesobtainedpriortoantibioticadministration.3.Fromthetimeofpresentation,broad-spectrumantibioticsadministeredwithin3hoursforEDadmissionsand1hourfornon-EDICUadmissions.LevyMMetal.IntensiveCareMed.2010;36(2):222-31.SepsisResuscitationBundle（first6hrs）4.Intheeventofhypotensionand/orlactate>4mmol/L(36mg/dl):a)Deliveraninitialminimumof20ml/kgofcrystalloid(orcolloidequivalent).b)Applyvasopressorsforhypotensionnotrespondingtoinitialfluidresuscitationtomaintainmeanarterialpressure(MAP)>65mmHg.LevyMMetal.IntensiveCareMed.2010;36(2):222-31.SepsisResuscitationBundle（first6hrs）5.Intheeventofpersistenthypotensiondespitefluidresuscitation(septicshock)and/orlactate>4mmol/L(36mg/dl):a)Achievecentralvenouspressure(CVP)of>8mmHg.b)Achievecentralvenousoxygensaturation(ScvO2)of>70%.*LevyMMetal.IntensiveCareMed.2010;36(2):222-31.1.Low-dosesteroidsadministeredforsepticshockinaccordancewithastandardizedhospitalpolicy.2.Drotrecoginalfa(activated)administeredinaccordancewithastandardizedhospitalpolicy.SepsisManagementBundle（first24hrs）LevyMMetal.IntensiveCareMed.2010;36(2):222-31.3.Glucosecontrolmaintained>lowerlimitofnormal,but<150mg/dl(8.3mmol/L).4.Inspiratoryplateaupressuresmaintained<30cmH2Oformechanicallyventilatedpatients.SepsisManagementBundle（first24hrs）LevyMMetal.IntensiveCareMed.2010;36(2):222-31.MainresultsDatafrom15,022subjectsat165siteswereanalyzedtodeterminethecompliancewithbundletargetsandassociationwithhospitalmortality.LevyMMetal.IntensiveCareMed.2010;36(2):222-31.MainresultsCompliancewiththeentireresuscitationbundleincreasedlinearlyfrom10.9%inthefirstsitequarterto31.3%bytheendof2years(P<0.0001).Compliancewiththeentiremanagementbundlestartedat18.4%inthefirstquarterandincreasedto36.1%bytheendof2years(P=0.008).LevyMMetal.IntensiveCareMed.2010;36(2):222-31.MainresultsUnadjustedhospitalmortalitydecreasedfrom37to30.8%over2years(P=0.001).TheadjustedoddsratioformortalityimprovedthelongerasitewasintheCampaign,resultinginanadjustedabsolutedropof0.8%perquarterand5.4%over2years(95%CI,2.5–8.4%).LevyMMetal.IntensiveCareMed.2010;36(2):222-31.补什么：晶体or胶体？R.PhillipDellingeretal.CritCareMed.2008;36(1):296-327.Werecommendfluidresuscitationwitheithernatural/artificialcolloidsorcrystalloids.Thereisnoevidence-basedsupportforonetypeoffluidoveranother(Grade1B).R.PhillipDellingeretal.CritCareMed.2008;36(1):296-327.液体复苏-2004年SAFE研究随机对照多中心研究共6997例需要液体复苏的ICU病人观察28天的结果组别：干预组：34974%人血白蛋白对照组：3500生理盐水NEnglJMed2004;350:2247-56.结论在液体复苏时，应用4%白蛋白与生理盐水在28天内效果相当；NEnglJMed2004;350:2247-56.亚组分析脓毒性休克：死亡率有减少趋势（30.7%vs35.3%，P=0.09）创伤病人，特别是脑外伤病人：死亡率有增加趋势（13.6%vs10.0%，P=0.06）NEnglJMed2004;350:2247-56.SurvivingSepsisCampaignPreviewsUpdatedGuidelinesfor2012

AdditionstoFluidTherapyRecommendations（2012）Withregardtofluidtherapy,theuseofcrystalloidsintheinitialfluidresuscitationinseveresepsisisrecommended(strongrecommendation;Grade1A).AdditionstoFluidTherapyRecommendations（2012）Werecommendthatinitialfluidchallengeinpatientswithsepsis-inducedtissueperfusionwithsuspicionofhypovolemnicbe1,000mLofcrystalloidsormoretoachieveaminimumof30mL/kgofcrystalloidsinthefirstfourtosixhours.AdditionstoFluidTherapyRecommendations（2012）Theresearchersalsosuggestaddingalbumintotheinitialfluidresuscitationforseveresepsisandsepticshock(weakrecommendation;Grade2B).DelaneyAPetal.CritCareMed.2011;39(2):386-91.DelaneyAPetal.CritCareMed.2011;39(2):386-91.DelaneyAPetal.CritCareMed.2011;39(2):386-91.Conclusions:Inthismeta-analysis,theuseofalbumin-containingsolutionsfortheresuscitationofpatientswithsepsiswasassociatedwithlowermortalitycomparedwithotherfluidresuscitationregimens.Untiltheresultsofongoingrandomizedcontrolledtrialsareknown,cliniciansshouldconsidertheuseofalbumin-containingsolutionsfortheresuscitationofpatientswithsepsis.DelaneyAPetal.CritCareMed.2011;39(2):386-91.AdditionstoFluidTherapyRecommendations（2012）Theyrecommendagainsttheuseofhydroxyethylstarches(hetastarches)withmolecularweightgreaterthan200daltonoradegreeofsubstitutionofmorethan0.4(strongrecommendation;Grade1B).“Wearesilentontheuseofhetastarchesoflowermolecularweightpendingtheresultsofongoingtrialsandwearealsosilentontheuseofgelatins,”Dellingernoted.CONCLUSIONSPatientswithseveresepsisassignedtofluidresuscitationwithHES130/0.4hadanincreasedriskofdeathatday90andweremorelikelytorequirerenal-replacementtherapy,ascomparedwiththosereceivingRinger’sacetate.(FundedbytheDanishResearchCouncilandothers;6SClinicalTnumber,NCT00962156.)ReinhartKetal.IntensiveCareMed.2012;38(3):368-83.RecommendationsandconclusionsWerecommendnottouseHESwithmolecularweight≥200kDaand/ordegreeofsubstitution>0.4inpatientswithseveresepsisorriskofacutekidneyinjuryandsuggestnottouse6%HES130/0.4orgelatininthesepopulations.ReinhartKetal.IntensiveCareMed.2012;38(3):368-83.RecommendationsandconclusionsWerecommendnottousecolloidsinpatientswithheadinjuryandnottoadministergelatinsandHESinorgandonors.ReinhartKetal.IntensiveCareMed.2012;38(3):368-83.RecommendationsandconclusionsWesuggestnottousehyperoncoticsolutionsforfluidresuscitation.Untiltheresultsoftheongoingstudies(ESM)becomeavailableandintheabsenceofotherRCTscomparingtheuseofhyperoncoticalbuminwithotherfluidforshockresuscitation,thesafetyofhyperoncoticalbuminremainsunclearforthecorrectionofhypoalbuminaemiaandforresuscitationinshock.ReinhartKetal.IntensiveCareMed.2012;38(3):368-83.RecommendationsandconclusionsWeconcludeandrecommendthatanynewcolloidshouldbeintroducedintoclinicalpracticeonlyafteritspatient-importantsafetyparametersareestablishedReinhartKetal.IntensiveCareMed.2012;38(3):368-83.BrochardLetal.AmJRespirCritCareMed.2010;181(10):1128-55.PanelrecommendationsWeconsiderfluidresuscitationwithcrystalloidstobeaseffectiveandsafeasfluidresuscitationwithhypooncoticcolloids(gelatinsand4%albumin).Basedoncurrentknowledge,werecommendthathyperoncoticsolutions(dextrans,hydroxyethylstarches,or20-25%albumin)notbeusedforroutinefluidresuscitationbecausetheycarryariskforrenaldysfunction.BrochardLetal.AmJRespirCritCareMed.2010;181(10):1128-55.Decreasedglomerularfiltrationpressureduetoincreasedintracapillaryoncoticpressureand(direct)colloidnephrotoxicity(osmoticnephrosis)arethetwopurportedmechanismsresponsibleforthehigherincidenceofrenaldysfunctionwithhyperoncoticcolloidsthanwithcrystalloidsorhypooncoticcolloids.BrochardLetal.AmJRespirCritCareMed.2010;181(10):1128-55.Inaddition,manyadverseeffectshavebeendescribedusingsyntheticcolloids.Theseincludeanaphylacticandanaphylactoidreactions,bloodcoagulationdisorders,and,inthecaseofstarches,alsoliverfailureandpruritus.BrochardLetal.AmJRespirCritCareMed.2010;181(10):1128-55.补多少？&补多快？Resuscitationgoals:(1C)CVP8-12mmHg(AhighertargetCVPof12-15mmHgisrecommendedinthepresenceofmechanicalventilationorpre-existingdecreasedventricularcompliance.)MAP≥65mmHgUrineoutput≥0.5mL.kg-1.hr-1Centralvenous(superiorvenacava)oxygensaturation≥70%,ormixedvenous≥65%R.PhillipDellingeretal.CritCareMed.2008;36(1):296-327.CVP8-12mmHg?Frank-StarlingCurve心室P-V曲线MarikPEetal.AnnIntensiveCare.2011;1(1):1.MarikPEetal.AnnIntensiveCare.2011;1(1):1.DoesCentralVenousPressurePredict

FluidResponsiveness?MarikPEetal.Chest.2008;134(1):172-8.Conclusions:ThissystematicreviewdemonstratedaverypoorrelationshipbetweenCVPandbloodvolumeaswellastheinabilityofCVP/ΔCVPtopredictthehemodynamicresponsetoafluidchallenge.CVPshouldnotbeusedtomakeclinicaldecisionsregardingfluidmanagement.MarikPEetal.Chest.2008;134(1):172-8.DiscussionInotherwords,ourresultssuggestthatatanyCVPthelikelihoodthatCVPcanaccuratelypredictfluidresponsivenessisonly56%(nobetterthanflippingacoin).Furthermore,anAUCof0.56suggeststhatthereisnoclearcutoffpointthathelpsthephysiciantodetermineifthepatientis“wet”or“dry”.MarikPEetal.Chest.2008;134(1):172-8.DiscussionItisimportanttoemphasizethatapatientisequallylikelytobefluidresponsivewithaloworahighCVP.TheresultsfromthisstudythereforeconfirmthatneitherahighCVP,anormalCVP,alowCVP,northeresponseoftheCVPtofluidloadingshouldbeusedinthefluidmanagementstrategyofanypatient.MarikPEetal.Chest.2008;134(1):172-8.DiscussionItshouldalsoberecognizedthatCVPwasacomponentofearlygoal-directedtherapyinthela