关注危重病人液体平衡(定稿)VIP免费

关注危重病人液体平衡徐颖鹤目录•EGDT提高抢救成功率•液体超负荷增加危重病人死亡率•CVP监测能准确指导液体复苏吗？•白蛋白用于液体复苏新观点EarlyGoal-DirectedTherapy(EGDT):involvesadjustmentsofcardiacpreload,afterload,andcontractilitytobalanceO2deliverywithO2demandChest1992;101:1644..EarlyGoal-DirectedTherapyintheTreatmentofSevereSepsisandSepticShockRiversE,NguyenB,HavstadS,etal.Earlygoal-directedtherapyinthetreatmentofseveresepsisandsepticshock.NEJM2001;345:1368.Studypurpose:toevaluatetheefficacyofearlygoal-directedtherapyinpatientspresentingtoanemergencydepartmentwithseveresepsisorsepticshock(priortoICUadmission)Studydesign:prospective,randomizedcontrolled,partiallyblinded,singlecentertrialPatientrandomizedN=263EarlygoaldirectedtherapyN=130StandardtherapyN=133CVP>8-12mmHgMAP>65mmHgUrineOutput>0.5ml/kg/hrCVP>8-12mmHgMAP>65mmHgUrineOutput>0.5ml/kg/hrScvO2>70%SaO2>93%Hct>30%AntibioticsgivenatdiscretionoftreatingcliniciansAssoonaspossibleMean6.2hrsICUMDsblindedtostudytreatmentNEJM2001;345:1368-77.Atleast6hoursofEGDTMean8hrsTransfertoICUCVP:centralvenouspressureMAP:meanarterialpressureScvO2:centralvenousoxygensaturationEarlyGoal-DirectedTherapyNEJM2001;345:1368-77.49.2%33.3%0102030405060StandardTherapyN=133EGDTN=130P=0.01**KeydifferencewasinsuddenCVcollapse,notMODSEarlyGoal-DirectedTherapyResults:28DayMortalitySuddenCVCollapseMODS21%vs10%p=0.0222%vs16%P=0.27NEJM2001;345:1368-77.Mortality质疑点质疑点质疑点CVP监测能准确指导液体复苏吗？Objective:Asystematicreviewoftheliteraturetodeterminethefollowing:(1)therelationshipbetweenCVPandbloodvolume,(2)theabilityofCVPtopredictfluidresponsiveness,(3)theabilityofthechangeinCVP(CVP)topredictfluidresponsiveness.ThepooledcorrelationcoefficientbetweentheCVPandmeasuredbloodvolumewas0.16(95%CI,0.03to0.28;r=0.02).1、ThepooledcorrelationcoefficientbetweenbaselineCVPandchangeinstrokeindex/cardiacindexwas0.182、ThepooledareaundertheROCcurvewas0.563、ThepooledcorrelationbetweenCVPandchangeinstrokeindex/cardiacindexwas0.114、ThebaselineCVPwas8.7-2.3mmHgintheresponders,ascomparedto9.7-2.2mmHginnonresponders(notsignficant;p0.3).结论•1、CVP与血容量之间相关性很低•2、CVP或者△CVP没有能力判定补液对血流动力学的影响•3、CVP不应该用于医生决策液体治疗FluidResuscitationinSepticshockAPositiveFluidBalanceandElevatedCentralVenousPressureAreAssociatedWithIncreasedMortality•回归性分析•TheVasopressininSepticShockTrial(VASST)study•778为感染性休克患者•研究目的是确定CVP、液体平衡与死亡率关系CritCareMed.2011;39(2):259-6512h液体平衡与CVP有关联，24小时就没有关联CVPGroupNetFluidBalancepSurvivorsNonsurvivorsAllPatients3444(1861–5984)mL4429(2537–6560)mL<.001CVP<8mmHg3015(1296–4987)mL2281(802–5711)mLNSCVP8–12mmHg2727(1227–5491)mL3112(1559–4809)mLNSCVP>12mmHg3975(2387–6614)mL5237(3140–7773)mL<.001Stopfillingpatientsagainstcentralvenouspressure,please!*CritCareMed2011Vol.39,No.2LeesN,HamiltonM,RhodesA:Clinicalreview:Goal-directedtherapyinhighrisksurgicalpatients.CritCare2009;13:231修正的EGDT试验1.镇静镇痛2.液体反应性：CVP动态变化；对于正压通气患者SVV/PPV3.滴定MAP75~85mmHg4.P(cv-a)CO25.血管活性药撤离试验血管活性药物撤离试验液体超负荷，我们要重视的问题！PayenS,etal,fortheSepsisOccurrenceinAcutelyIllPatients(SOAP)Investigators:Apositivefluidbalanceisassociatedwithaworseoutcomeinpatientswithacuterenalfailure.CritCare12:R74,2008液体积聚在为重病人中经常发生Fl...