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1、Sepsis患者的液体管理p 患者，男，39岁 。p主诉：右下腹痛伴发热3天,加重1天。p8月14日入急诊室，8月15日1405入院。Case p腹痛待查p局限性腹膜炎p急性阑尾炎 入普外科时诊断p感染性休克p急性坏疽性阑尾炎p阑尾周围脓肿 p阑尾切除术后pARDSp I型呼吸衰竭入ICU诊断p8.15 术中进量 1000ml, 出血 20mlpDATE IN OUT Balance Tmax p8.16 4450 1800 +2650 36.8p8.17 1610 4490 -1880 37.3p8.18 1250 2450 -1200 37.5p8.19 1860 2740 -880 37
2、.3Fluid BalanceARDS(急性呼吸窘迫综合征)静脉输液的历史The discovery of the circulation of the blood by William Harvey in 1628 formed the basis for the rationale for IV injections and infusions输液目的普通静脉输液（按要求稀释药物）容量复苏Volume resuscitation(液体复苏 Fluid resuscitation)（补充患者体内不足）Fluid is a drug that can be overdosed in the I
3、CUS.L Goldstein Department of Nephrology and HypertensionCincinnati Childrens Hospital Medical Center, USA如何实施液体管理？没有明确答案在中国In the ICU:重症患者In the wards:前重症患者or重症患者Patients with SIRS毛细血管渗漏综合征（Capillary Leak Syndrome，CLS） l定义l毛细血管内皮细胞损伤，血管通透性增高，造成间质水肿（如肺泡水肿，气体交换受限），组织缺氧又加重毛细血管内皮细胞损伤，形成恶性循环，引起器官功能障碍l病因
4、l严重创伤、Sepsis、ARDS、烧伤、体外循环手术、再灌注损伤等。l主要表现l一般：全身水肿，血液浓缩，低蛋白血症l器官：肺，肝，脑各种情况下的水的分布内毒素血症-高容量组高容量复苏与死亡率：高容量复苏与死亡率：动物实验动物实验内毒素血症-中等容量组腹膜炎-高容量组腹膜炎-中等容量组结论结论 高容量复苏增加脓毒症的死亡率。液体管理策略影响脓毒症的预后。生存率大量研究表明：大量研究表明：液体过多与预后不佳有关液体过多与预后不佳有关1. Simmons RS, Berdine GG, Seidenfeld JJ, et al: Fluid balance and the adult respi
5、ratory distress syndrome. Am Rev Respir Dis 1987;135:9249292. Humphrey H, Hall J, Sznajder I, et al: Improved survival in ARDS patients associated with a reduction in pulmonary capillary wedge pressure. Chest 1990; 97:117611803. Schuller D, Mitchell JP, Calandrino FS, et al: Fluid balance during pul
6、monary edema. Is fluid gain a marker or a cause of poor outcome? Chest 1991; 100:106810754.Alsous F, Khamiees M, DeGirolamo A, et al: Negative fluid balance predicts survival in patients with septic shock: A retrospective pilot study. Chest 2000; 117:17491754大量研究表明：大量研究表明：液体过多与预后不佳有关液体过多与预后不佳有关5. Ri
7、vers E, Nguyen B, Havstad S, et al : Early Goal-Directed Therapy Collaborative Group: Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001; 345:136813776. Sakr Y, Vincent JL, Reinhart K, et al; Sepsis Occurence in Acutely Ill Patients Investigators: High
8、tidal volume and positive fluid balance are associated with worse outcome in acute lung injury. Chest 2005; 128:309831087. Vincent JL, Sakr Y, Sprung CL, et al: Sepsis Occurrence in Acutely Ill Patients Investigators: Sepsis in European intensive care units: Results of the SOAP study. Crit Care Med
9、2006; 34:3443538. Rosenberg AL, Dechert RE, Park PK, et al: NIH NHLBI ARDS Network: Review of a large clinical series: Association of cumulative fluid balance on outcome in acute lung injury: A retrospective review of the ARDSnet tidal volume study cohort. J Intensive Care Med 2009; 24:3546大量研究表明：大量
10、研究表明：液体过多与预后不佳有关液体过多与预后不佳有关9. Rosenberg AL, Dechert RE, Park PK, et al; NIH NHLBI ARDS Network: Review of a large clinical series: Association of cumulative fluid balance on outcome in acute lung injury: A retrospective review of the ARDSnet tidal volume study cohort. J Intensive Care Med 2009; 24:3
11、54610. Stewart RM, Park PK, Hunt JP, et al; National Institutes of Health/National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome Clinical Trials Network: Less is more: Improved outcomes in surgical patients with conservative fluid administration and central venous catheter mon
12、itoring. J Am Coll Surg 2009; 208:72573511. Boyd JH, Forbes J, Nakada TA, et al: Fluid resuscitation in septic shock: A positive fluid balance and elevated central venous pressure are associated with increased mortality. Crit Care Med 2011; 39:25926512. The RENAL Replacement Therapy Study Investigat
13、ors: An observational study of fluid balance and patient outcomes in the randomized evaluation of normal vs. augmented level of replacement therapy trial. Crit Care Med 2012; 40:17531760静态评估动态评估两种序贯容量管理策略两种序贯容量管理策略Adequate initial fluid resuscitation (AIFR)早期恰当容量复苏早期恰当容量复苏 administration of an initi
14、al fluid bolus of 20 mL/kg prior to to vasopressor therapy initiation and achievement of a central venous pressure of 8 mm Hg within 6 h after the onset of therapy with vasopressorsConservative late fluid management (CLFM)后期限制性液体管理后期限制性液体管理 even-to-negative fluid balance measured on at least 2 conse
15、cutive days during the first 7 days after septic shock onset何谓何谓“限制性容量管理限制性容量管理”（conservative or restricted fluid management）维持每日液体进出量基本或维持每日液体进出量基本或(尽可能尽可能)负平负平衡衡 Daily even-to-negative fluid balance 满足细胞、组织适当的灌注满足细胞、组织适当的灌注为细胞、组织提供足够的氧气、足够的营养为细胞、组织提供足够的氧气、足够的营养维持重要器官功能维持重要器官功能Fluid may be a friend
16、 when appropriately titratedduring the resuscitation, or ebb, phase ofacute lung injury. However, excess fluid becomesan enemy when it is no longer physiologicallyneeded.Emanuel P. Rivers, M.D., M.P.H.Fluid-Management Strategies in Acute Lung Injury Liberal, Conservative, or Both? N Engl J Med 354;24 2598 june 15, 2006
