icu

败血症和出血性休克的体液复苏

Fluid Resuscitation in Sepsis and Hemorrhagic Shock: What Do the Data Show?
Antonios Liolios, MD
Introduction
Fluid therapy is now considered an invaluable component of therapy for sepsis; vasopressors are reserved as second-line choices for the patient not responding to volume loading. Disagreements have emerged regarding the optimal fluid for sepsis fluid therapy, the target volume, as well as the timing of administration. A panel, assembled at the 32nd Critical Care Congress, discussed the controversies surrounding crystalloid and colloid fluid resuscitation, emphasizing sepsis and hemorrhagic shock.
　

　Fluid Resuscitation: Perioperative Optimization of the High-Risk Patient
　　Role of Synthetic Colloids in Resuscitation
　　Use of Albumin in Resuscitation
　　Use of Hypertonic Fluid Solutions in Hemorrhagic Shock
　　Role of Hypertonic Solutions in Septic Shock
　　Early Goal-Directed Resuscitation Therapy in Sepsis
Conclusions
　　Volume therapy appears to be the most important factor for perioperative optimization of the high-risk patient and for the resuscitation of the septic patient. There are no compelling differences between colloids and crystalloids as long as they are used adequately for resuscitation, although there appear to be data that albumin supplementation might be beneficial in sepsis. Septic patients may present with misleadingly normal hemodynamic parameters despite global ischemia. These patients are at high risk for multiple organ failure and death. Aggressive early goal-directed therapy may significantly reduce this mortality. Hypertonic fluids have some interesting qualities, and further studies are needed to delineate their effectiveness and indications in patients in hemorrhagic and septic shock.
References
1. Bennett-Guerrero E. Resuscitation: fluid therapy. Pre-operative optimization of the high-risk patient. Program and abstracts of the 32nd Critical Care Congress; January 28-February 2, 2003; San Antonio, Texas.
2. Boyd O, Grounds RM, Bennett ED. A randomized clinical trial of the effect of deliberate perioperative increase of oxygen delivery on mortality in high-risk surgical patients. JAMA. 1993;270:2699-2707.
3. Wilson J, Woods I, Fawcett J, et al. Reducing the risk of major elective surgery: randomised controlled trial of preoperative optimisation of oxygen delivery. BMJ. 1999;318:1099-1103.
4. Lobo SM, Salgado PF, Castillo VG, et al. Effects of maximizing oxygen delivery on morbidity and mortality in high-risk surgical patients. Crit Care Med. 2000;28:3396-3404.
5. Takala J, Meier-Hellmann A, Eddleston J, Hulstaert P, Sramek V. Effect of dopexamine on outcome after major abdominal surgery: a prospective, randomized, controlled multicenter study. European Multicenter Study Group on Dopexamine in Major Abdominal Surgery. Crit Care Med. 2000;28:3417-3423.
6. Sandham JD, Hull RD, Brant RF, et al. A randomized, controlled trial of the use of pulmonary-artery catheters in high-risk surgical patients. N Engl J Med. 2003;348:5-14.
7. Sinclair S, James S, Singer M. Intraoperative intravascular volume optimisation and length of hospital stay after repair of proximal femoral fracture: randomised controlled trial. BMJ. 1997;315:909-912.
8. Venn R, Steele A, Richardson P, et al. Randomized controlled trial to investigate influence of the fluid challenge on duration of hospital stay and perioperative morbidity in patients with hip fractures. Br J Anaesth. 2002;88:65-71.
9. Kellum J. Resuscitation: fluid therapy. Synthetic colloids Program and abstracts of the 32nd Critical Care Congress; January 28-February 2, 2003; San Antonio, Texas.
10. Choi PT, Yip G, Quinonez LG, et al. Crystalloids vs. colloids in fluid resuscitation: a systematic review. Crit Care Med. 1999;27:200-210.
11. Boldt J, Heesen M, Muller M, et al. The effects of albumin versus hydroxyethyl starch solution on cardiorespiratory and circulatory variables in critically ill patients. Anesth Analg. 1996;83:254-261.
12. Human albumin administration in critically ill patients: systematic review of randomised controlled trials. Cochrane Injuries Group Albumin Reviewers. BMJ. 1998;317:235-240.
13. Schortgen F, Lacherade JC, Bruneel F, et al. Effects of hydroxyethylstarch and gelatin on renal function in severe sepsis: a multicentre randomised study. Lancet. 2001;357:911-916.
14. Bunn F, Alderson P, Hawkins V. Colloid solutions for fluid resuscitation. Cochrane Database Syst Rev. 2000:CD001319.
15. Gan TJ, Bennett-Guerrero E, Phillips-Bute B, et al. Hextend, a physiologically balanced plasma expander for large volume use in major surgery: a randomized phase III clinical trial. Hextend Study Group. Anesth Analg. 1999;88:992-998.
16. Vincent J-L. Resuscitation: fluid therapy. Effects of albumin resuscitation: results of a clinical trial. Program and abstracts of the 32nd Critical Care Congress; January 28-February 2, 2003; San Antonio, Texas.
17. Barle H, Januszkiewicz A, Hallstrom L, et al. Albumin synthesis in humans increases immediately following the administration of endotoxin. Clin Sci. 2002;103:525-531.
18. Mangialardi RJ, Martin GS, Bernard GR, et al. Hypoproteinemia predicts acute respiratory distress syndrome development, weight gain, and death in patients with sepsis. Ibuprofen in Sepsis Study Group. Crit Care Med. 2000;28:3137-3145.
19. Martin GS, Mangialardi RJ, Wheeler AP, et al. Albumin and furosemide therapy in hypoproteinemic patients with acute lung injury. Crit Care Med. 2002;30:2175-2182.
20. Hoyt D. Resuscitation: fluid therapy. Hypertonic fluids solutions in hemorrhagic shock. Program and abstracts of the 32nd Critical Care Congress; January 28-February 2, 2003; San Antonio, Texas.
21. Sauaia A, Moore FA, Moore EE, et al. Epidemiology of trauma deaths: a reassessment. J Trauma. 1995;38:185-193.
22. Angle N, Cabello-Passini R, Hoyt DB, et al. Hypertonic saline infusion: can it regulate human neutrophil function? Shock. 2000;14:503-508.
23. Mattox KL, Maningas PA, Moore EE, et al. Prehospital hypertonic saline/dextran infusion for post-traumatic hypotension. The U.S.A. Multicenter Trial. Ann Surg. 1991;213:482-491.
24. Vassar MJ, Fischer RP, O'Brien PE, et al. A multicenter trial for resuscitation of injured patients with 7.5% sodium chloride. The effect of added dextran 70. The Multicenter Group for the Study of Hypertonic Saline in Trauma Patients. Arch Surg. 1993;128:1003-1011; discussion 1011-1013.
25. Wade CE, Kramer GC, Grady JJ, et al. Efficacy of hypertonic 7.5% saline and 6% dextran-70 in treating trauma: a meta-analysis of controlled clinical studies. Surgery. 1997;122:609-616.
26. Vincent J-L. Resuscitation: fluid therapy. Hypertonic fluids in septic shock. Program and abstracts of the 32nd Critical Care Congress; January 28-February 2, 2003; San Antonio, Texas.
27. Rizoli SB, Kapus A, Fan J, et al. Immunomodulatory effects of hypertonic resuscitation on the development of lung inflammation following hemorrhagic shock. J Immunol. 1998;161:6288-6296.
28. Oliveira RP, Weingartner R, Ribas EO, et al. Acute haemodynamic effects of a hypertonic saline/dextran solution in stable patients with severe sepsis. Intensive Care Med. 2002;28:1574-1581.
29. Rivers E. Resuscitation: fluid therapy. Early goal-directed resuscitation of sepsis: From the emergency room to the ICU. Program and abstracts of the 32nd Critical Care Congress; January 28-February 2, 2003; San Antonio, Texas.
30. Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345:1368-1377.
____________________________________________________