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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多年前（1832年）， 一位苏格兰医师，发现了这种通过静脉血管把药液送入人体的治疗手段,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）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
2、皂水，人体血液）,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，白蛋白含量约为35-50g/L（占血浆总蛋白的60%),2018/10/16,Frank-Starling 定律,(Multi-) Organ Failure,Microcirculatory dysfunction,What else besides volume restriction and expansion?,Fluid resuscitation,Tissue oxygenati
3、on,Capillary leak amelioration,Hemodynamics,Clinical outocme,Risk of Anaphylaxis,Effect on coagulation,Effect on Renal function,Jean-Louis Vincent, Max Harry Weil, Crit Care Med 2006; 34:13331337,Introduction,Acutely ill patients frequently require fluid repletion. Hypovolemia External loss: bleedin
4、g, gastrointestinal, urinary tracts, skin Internal loss: extravasation of blood, exudation / transudation of fluids Relative Hypovolemia: increases venous capacitance Sepsis, drugsVolume repletion may be essential to restore critical levels of cardiac output and arterial pressure, resulting in more
5、normal perfusion of vital organs and tissues.,Jean-Louis Vincent, Max Harry Weil, Crit Care Med 2006; 34:13331337,Acutely ill patients frequently require fluid repletion Hypovolemia: external loss & internal loss Relative Hypovolemia: increases venous capacitanceVolume repletion may be essential Res
6、tore critical levels of cardiac output and arterial pressure More normal perfusion of vital organs and tissues,Jean-Louis Vincent, Max Harry Weil, Crit Care Med 2006; 34:13331337,Introduction,Hemorrhage: Benefit / risk of fluid repletion must be assessed Benefits of delayed resuscitation Large volum
7、e of fluid red cell deficit oxygen deficitPersistent hypovolemia will result in MODS,Fluid repletion is typically more effective during hypovolemic states but is less effective in later stages.,Jean-Louis Vincent, Max Harry Weil, Crit Care Med 2006; 34:13331337,“fluid challenge”,Jean-Louis Vincent,
8、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 unstable patients and offers three major advantages:Quantitation of the cardiovascular
9、response during volume infusion.Prompt correction of fluid deficits. Minimizing the risk of fluid overload and its potentially adverse effects, 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,高渗盐液 7.5%盐水+低右,晶体液复苏？,赞成使用晶体液的理由： 费用低，容易得到 对肾功能保持较好 很少产生不良反应。这几种液体都能纠正脱水 可纠正低钠血症 高渗盐水（HS）扩容效率高 反对
10、使用晶体液的理由： 平均留驻时间短（只有45min） 液体输入量大 造成血清白蛋白的稀释，血渗透压降低，间质水肿、肺水肿 稀释血中凝血因子 降低血小板计数和血红细胞压积 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, Boldt J, Suttner S, et al. Analg.2001.93:405-409.,The edema problem of crystalloids is we
11、ll known,“Fluid is poured into the interstitial space on clinical information gained from changes in intravascular space.The 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,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
12、：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 Today,COP balance essential for balanced flow across capillary胶体渗透压的平衡是毛细血管的交换的基本因素 Crystall
13、oids cannot impact COP Edema单独使用晶体无法维持胶体渗透压水肿,Colloids help to restore COP 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
14、 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： 维持血流动力学稳定 维持血浆胶体渗透压 改善微循环改善组织细胞氧供 非容量作用： 改善CLS 改善炎性反应 物质结合和转运 抗氧化作用 ,(colloid)151 consecutively major trauma patients,William C. Shoemaker Outcome Prediction of Emergency Patients by Noninvasive Hemodynamic Monitor
15、ing Chest. 2001;120:528-537,William C. Shoemaker Outcome Prediction of Emergency Patients by Noninvasive Hemodynamic Monitoring Chest. 2001;120:528-537,Hemodynamcs（ crystalloid ）: 151 consecutively major trauma patients,Normal,Substance P- 1 min later,Study of Capillary Leak,Direct: Scanning EM: nor
16、mal endothelial cell junction Donald McDonald 1999,Crit Care Med 2006; 34:17751782,白蛋白增加血浆中抗氧化剂硫醇含量,Gregory J. etc. Crit Care Med. 2004;32:755-759,白蛋白增加血浆中抗氧化剂含量,Gregory J. etc. Crit Care Med. 2004;32:755-759,The SAFE Study,Alb: saline deaths 726:729 (RR 0.99) Similar new organ failures ICU LOS Hospital LOS Ventilator duration RRT Conclusion: Outcome with albumin in ICU no different from Saline,
