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1、液体复苏-胶体的地位 中山大学 附属第一医院 重症医学科 管向东 -170-170多年前（多年前（18321832年），年）， 一位苏格兰医师，发现了这种通过一位苏格兰医师，发现了这种通过静脉静脉 血管把药液送入人体的治疗手段血管把药液送入人体的治疗手段 明胶 GELATIN 白蛋白 ALBUMIN 1915 World War I 1945 World War II 1960 War In Vietnam 右旋糖苷 DEXTRAN 羟乙基淀粉 1943 World War II 为什么要开发出这些胶体? 重症液体复苏的重要性 胶体及其作用 目前的争论 总结 什么是胶体? 胶体（colloid
2、）又称胶状分散体（colloidal dispersion ） 是一种均匀混合物，在胶体中含有两种不同相态的物 质，一种分散，另一种连续。分散的一部分是由微小 的粒子或液滴所组成，大小介于1到100纳米之间，且 几乎遍布在整个连续相态中。 按分散剂的不同可分为： 气溶胶(雾、烟、云)； 固溶胶(水晶、有色玻璃) 液溶胶（蛋白溶液，淀粉溶液，肥皂水，人体血液 ） 人体白蛋白的含量与分布人体白蛋白的含量与分布 细胞 内液 细胞 外液 体液 -约占人体 体重60% 40% 组织间 液 15% 血浆5% 蛋白质在血浆中含 量远远高于组织间 液 血浆总蛋白含量约 为60-80g/L 其中，白蛋白含量 约
3、为35-50g/L（占 血浆总蛋白的60%) * Frank-Starling 定律 (Multi-) Organ Failure(Multi-) Organ Failure Cell dystructionCell dystruction by imbalance between by imbalance between OO2 2 - supply and - supply and OO 2 2 - consumption - consumption OO 2 2 undersupportundersupport OO 2 2 debtdebt MacrocirculatoryMacroc
4、irculatory dysfunctiondysfunction CO MicrocirculatoryMicrocirculatory dysfunctiondysfunction What else besides volume restriction and expansion? Fluid resuscitation Tissue oxygenation Capillary leak amelioration Hemodynamics Clinical outocme Risk of Anaphylaxis Effect on coagulation Effect on Renal
5、function Jean-Louis Vincent, Max Harry Weil, Crit Care Med 2006; 34:13331337 Introduction Acutely ill patients frequently require fluid repletion. Hypovolemia External loss: bleeding, gastrointestinal, urinary tracts, skin Internal loss: extravasation of blood, exudation / transudation of fluids Rel
6、ative Hypovolemia: increases venous capacitance Sepsis, drugs Volume repletion may be essential to restore critical levels of cardiac output and arterial pressure, resulting in more normal perfusion of vital organs and tissues. Jean-Louis Vincent, Max Harry Weil, Crit Care Med 2006; 34:13331337 Acut
7、ely ill patients frequently require fluid repletion Hypovolemia: external loss 34:13331337 Introduction HemorrhageHemorrhage: Benefit / risk of fluid repletion must be assessed Benefits of delayed resuscitation Large volume of fluid red cell deficit oxygen deficit Persistent hypovolemia will result
8、in MODS Fluid repletion is typically more effective during Fluid repletion is typically more effective during hypovolemic states hypovolemic states but is less effective in later stages.but is less effective in later stages. Jean-Louis Vincent, Max Harry Weil, Crit Care Med 2006; 34:13331337 “fluid
9、challenge“fluid challenge” ” Jean-Louis Vincent, Max Harry Weil, Crit Care Med 2006; 34:13331337 Distinguished from conventional fluid administration Usually to critical patients with cardiorespiratory failure The fluid challenge is reserved for hemodynamically unstablehemodynamically unstable patie
10、nts and offers three major advantages: 1.1.QuantitationQuantitation of the cardiovascular response during of the cardiovascular response during volume infusion.volume infusion. 2.2.Prompt correctionPrompt correction of fluid deficits. of fluid deficits. 3.3.Minimizing the risk of fluid overloadMinim
11、izing the risk of fluid overload and its potentially and its potentially adverse effects, adverse effects, especially on the lungs.especially on the lungs. 重症液体复苏的重要性 胶体及其作用 目前的争论 总结 复苏液体种类 白蛋白 血浆? 明胶 胶体液晶体液 林格氏液 生理盐水 右旋糖苷羟乙基淀粉 改良明胶HES200/0.5 HES130/0.4 尿联明胶 聚明胶肽 天然胶体人工胶体 高渗盐液 7.5%盐水 +低右 晶体液复苏？ z赞成使
12、用晶体液的理由： z费用低，容易得到 z对肾功能保持较好 z很少产生不良反应。这几种液体都能纠正脱水 z可纠正低钠血症 z高渗盐水（HS）扩容效率高 z反对使用晶体液的理由： z平均留驻时间短（只有45min） z液体输入量大 z造成血清白蛋白的稀释，血渗透压降低，间质水肿、肺水肿 z稀释血中凝血因子 z降低血小板计数和血红细胞压积 z血液携氧能力下降，降低组织氧合 Koustova E, Stanton K, Gushchin V, et al. Trauma 2002;52:872- 878. Rotstein OD. Trauma 2000;49:580-83. Lang K, Bold
13、t J, Suttner S, et al. Analg.2001.93:405-409. The edema problem of crystalloids is well known u“Fluid is poured into the interstitial space on clinical information gained from changes in intravascular space. uThe end point,.peripheral or pulmonary edema” Twigley 40:860-871 因生存率下降 NHLBI 终止高张盐水治疗休克的研究
14、 NIH所属的国立心肺血液研究所(NHLBI)已经终止了一项有 关严重出血导致休克的创伤患者的临床液体复苏干预试验 该试验旨在研究高张盐水溶液治疗此类患者疗效及安全性 试验终止的原因：观察到高张盐水治疗组患者在到达医院 或急诊科前病死率显著升高，尽管高张盐水组及生理盐水 组患者28天病死率（研究终点）相似 NHLBI Halts Study of Concentrated Saline for Shock Due to Lack of Survival Benefit. American Academy of Emergency Medicine 2009 - 16 (3), MedScape
15、 Today COP balance essential for balanced flow across COP balance essential for balanced flow across capillarycapillary 胶体渗透压的平衡是毛细血管的交换的基本因素胶体渗透压的平衡是毛细血管的交换的基本因素 Crystalloids cannot Crystalloids cannot impactimpact COP Edema COP Edema 单独使用晶体无法维持胶体渗透压单独使用晶体无法维持胶体渗透压水肿水肿 Colloids help to restore COP
16、and reduce Crystalloid load 胶体液有助于恢复胶体渗透压和减少晶体负荷 Artery (Arteriole) 动脉,小动脉 Vein (Venule) 静脉,小静脉 Plasma Protein Colloid Osmotic Pressure 胶体渗透压22 mm Hg 简化Starling定律 Hydrostatic Pressure 静水压32 mm Hg Hydrostatic Pressure 静水压12 mm Hg Tissue Fluid 组织液 Hypovolemia Edema, organ damage 低血容量 水肿, 器官损伤 胶体渗透压 胶体液的作用 容量作用：容量作用： 维持血流动
