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1、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,Early Goal-Directed Therapy (EGDT): involves adjustments of cardiac preload, afterload, and contractility to balance O2 delivery with O2 demand,Chest 1992;101:1644.,Early Goal-Directed Therapy in the Treatment of Severe Sepsi
2、s and Septic Shock,Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. NEJM 2001;345:1368.,Study purpose: to evaluate the efficacy of early goal-directed therapy in patients presenting to an emergency department with severe sepsis or
3、septic shock (prior to ICU admission) Study design: prospective, randomized controlled, partially blinded, single center trial,CVP 8-12 mm Hg MAP 65 mm Hg Urine Output 0.5 ml/kg/hr,CVP 8-12 mm Hg MAP 65 mm Hg Urine Output 0.5 ml/kg/hr ScvO2 70% SaO2 93% Hct 30%,Antibiotics given at discretion of tre
4、ating clinicians,ICU MDs blinded to study treatment,NEJM 2001;345:1368-77.,At least 6 hours of EGDT Mean 8hrs,CVP: central venous pressure MAP: mean arterial pressure ScvO2: central venous oxygen saturation,Early Goal-Directed Therapy,NEJM 2001;345:1368-77.,49.2%,33.3%,0,10,20,30,40,50,60,Standard T
5、herapy N=133,EGDT N=130,P = 0.01*,*Key difference was in sudden CV collapse, not MODS,Early Goal-Directed Therapy Results: 28 Day Mortality,Sudden CV Collapse,MODS,21% vs 10% p=0.02,22% vs 16% P=0.27,NEJM 2001;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: A systematic review of the
6、literature to determine the following: the relationship between CVP and blood volume, the ability of CVP to predict fluid responsiveness, the ability of the change in CVP (CVP) to predict fluid responsiveness.,The pooled correlation coefficient between the CVP and measured blood volume was 0.16 (95%
7、 CI, 0.03 to 0.28; r= 0.02).,1、The pooled correlation coefficient between baseline CVP and change in stroke index/cardiac index was 0.18 2、The pooled area under the ROCcurve was 0.56 3、The pooled correlation between CVP and change in stroke index/cardiac index was 0.11 4、The baseline CVP was 8.7 -2.
8、3mm Hg in the responders, as compared to 9.7 - 2.2mm Hg in nonresponders (not signficant; p 0.3).,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,Fluid Resuscitation in Septic shock A Positive Fluid Balance and Elevated Central Venous Pressure Are Associated With Increased Mortali
9、ty,回归性分析 The Vasopressin in Septic Shock Trial (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,Crit Care Med. 2011;39(2):259-65,12h液体平衡与CVP有关联，24小时就没有关联,Stop filling patients against central venous pressure, please!*,Crit Care Med 2011 Vol. 39, No. 2,Lees N, Hamilton M, Rhodes A: Clinical review: Go
10、al-directed therapy in high risk surgical patients. Crit Care 2009; 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MAP7585mmHg 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！,Payen S, etal,for the Sepsis Occurrence in Acutely Ill Patients (SOAP)Investigators: A positive fluid balanc
11、e is associated with a worse outcome in patients with acute renal failure. Crit Care 12: R74, 2008,液体积聚在为重病人中经常发生,Fluid Resuscitation in Septic shock A Positive Fluid Balance and Elevated Central Venous Pressure Are Associated With Increased Mortality,回归性分析 The Vasopressin in Septic Shock Trial (VAS
12、ST) 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,Crit Care Med. 2011;39(2):259-65,12h液体正平衡4.2 3.8 L 第四天液体正平衡11 8.9 L,1、2与4相比，死亡率下降 3与4相比，有下降，但无统计学意义,结论：液体超负荷增加死亡风险,Vincent JL,et al: Sepsis in European intensive care units: results of the SOAP study. Crit Care Med 2006; 34:344353.,多因素回归分析表明：入院72小时液体平衡时独立的
13、结果预测指标：没增加1升的液体积聚，死亡风险增加,Fluid accumulation survival and recovery of kidney function in critically ill patients with acute kidney injury.,目的: If fluid accumulation is associated with mortality and non-recovery of kidney function in critically ill adults with acute kidney injury. 方法: Fluid overload w
14、as defined as more than a 10% increase in body weight relative to baseline, measured in 618 patients enrolled in a prospective multicenter observational study.,Kidney Int 2009,618 critically ill patients were examined the effect of fluid overload,Figure 2. Mortality rate by final fluid accumulation
15、relative to baseline weight and stratified by dialysis status. Reprinted from reference 20, with permission.,a highly significant correlation was observed between mortality and the proportion of days in which fluid overload was present (P0.0001). 结论： In patients with acute kidney injury, fluid overl
16、oad was independently associated with mortality.,The importance of fluid management in acute lung injury secondary to septic shock Chest 2009; 136: 102109,Adequate initial fluid resuscitation 是6h内给予大于20 ml/kg 液体和CVP大于 8 mm Hg. Conservative late fluid在7天内有2天达到液体平衡或负平衡,多因素回归分析不能达到限制液体管理的是独立的死亡危险因素,Wiedemann,-two fluid-management strategies, N Engl J Med ,2006,PURPOSE: Optimal fluid management in patients with acute lung injury METHODS: compared a conservative a
