危重患者的液体管理详解.ppt

Early Goal-Directed Therapy in the Treatment of Severe Sepsis and Septic Shock We randomly assigned patients who arrived at an urban emergency department with severe sepsis or septic shock to receive either six hours of early goal-directed therapy or standard therapy (as a control) before admission to the intensive care unit Rivers E, et al. N Engl J Med 2001; 345:1368–1377 标准治疗：CVP≥8 ~12 mm Hg、MAP≥ 65 mm Hg EGDT: 6 h达标，ScvO2≥ 70% 结果：EGDT需大量补液(4,981±2,984 mL vs 3,499±2,438 mL;P0.001),需要更多的多巴酚丁胺和RBC 标准治疗使乳酸酸中毒持续时间长、器官功能障碍多，院内病死率高(46.5% vs 30.5%). Rivers E, et al. N Engl J Med 2001; 345:1368–1377 Figure 4. Comparing the Pao2/Fio2 ratios between the EGDT and standard-care groups. Despite more volume resuscitation in the EGDT group during initial 6 h, there was no net difference in Pao2/Fio2 ratio (p =0.34). EGDT effect on coagulation defects (d-dimer). A significant decrease is seen in the level of d-dimer over 7 to 72 h in the EGDT group (p = 0.01). 强调对脓毒症的早期认识及早期干预 在疾病的早期阶段EGDT治疗策略的益处明显 推荐在脓毒症和脓毒症休克早期就应该考虑到EGDT，尽管这一时间段占整个住院时间很短，但是对整个疾病过程有很大的作用。这来源于对心功能的崩溃的早期识别及早期干预使氧输送和氧耗达到新的平衡。 Rivers E, et al. N Engl J Med 2001; 345:1368–1377 Emanuel P. Rivers 2006；354:2598-2600 Fluid-Management Strategies in Acute Lung Injury — Liberal, Conservative, or Both? EGDT是在患者进入医院的最初6小时即开始执 行， 一些研究者称之为侵略性的液体复苏（液体冲 击疗法），尽管在最初的6小时EGDT组液体量明显 高于对照组，但是前三天的液体总量是相同的。且 EGDT组的病死率，IL-18的水平，机械通气的需求 都是下降的。因此说液体管理的最初时间有非常重 要的作用（退潮期）。 胶体和晶体补液治疗同样有效 ，尚无优劣之分（1 B） 对于低血容量患者补液应从30分钟输注1000ml晶体液或300-500ml胶体液开始，对于组织灌注不良的患者则需要更快速、更大量补液（1 D） 当心脏充盈压提高而血流动力学未相应改善时应减少补液（1 D） SSC 2008 指南 2012 SSC严重脓毒症/感染性休克指南更新 ICU Conclusions :Although there was no significant difference in the primary outcome of 60-day mortality, the conservative strategy of fluid management improved lung function and shortened the duration of mechanical ventilation and intensive care without increasing nonpulmonary-organ failures. These