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1、Sepsis患者的液体管理,患者，男，39岁 。 主诉：右下腹痛伴发热3天,加重1天。 8月14日入急诊室，8月15日1405入院。,Case,腹痛待查 局限性腹膜炎 急性阑尾炎,入普外科时诊断,感染性休克 急性坏疽性阑尾炎 阑尾周围脓肿 阑尾切除术后 ARDS I型呼吸衰竭,入ICU诊断,8.15 术中进量 1000ml, 出血 20ml DATE IN OUT Balance Tmax 8.16 4450 1800 +2650 36.8 8.17 1610 4490 -1880 37.3 8.18 1250 2450 -1200 37.5 8.19 1860 2740 -880 37.3,
2、Fluid Balance,ARDS(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
3、the ICU,S.L Goldstein Department of Nephrology and Hypertension Cincinnati 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）,定义 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
4、循环，引起器官功能障碍 病因 严重创伤、Sepsis、ARDS、烧伤、体外循环手术、再灌注损伤等。 主要表现 一般：全身水肿，血液浓缩，低蛋白血症 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：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 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： 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 respiratory di
5、stress syndrome. Am Rev Respir Dis 1987;135:924929 2. Humphrey H, Hall J, Sznajder I, et al: Improved survival in ARDS patients associated with a reduction in pulmonary capillary wedge pressure. Chest 1990; 97:11761180 3. Schuller D, Mitchell JP, Calandrino FS, et al: Fluid balance during pulmonary
6、edema. Is fluid gain a marker or a cause of poor outcome? Chest 1991; 100:10681075 4.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： 液体过多与预后不佳有关,5. Rivers E, Nguyen B, Hav
7、stad 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; 345:13681377 6. Sakr Y, Vincent JL, Reinhart K, et al; Sepsis Occurence in Acutely Ill Patients Investigators: High tidal volume and pos
8、itive fluid balance are associated with worse outcome in acute lung injury. Chest 2005; 128:30983108 7. 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 2006; 34:344353 8.
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; 24:3546,大量研究表明： 液体过多与预后不佳有关,9. Ros
10、enberg 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 10. Stewart RM, Park PK, Hunt
11、 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 monitoring. J Am Coll Surg 2009; 20
12、8:725735 11. 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; 39:259265 12. The RENAL Replacement Therapy Study Investigators: An observational study of
13、 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,Adequate initial fluid resuscitation (AIFR) 早期恰当容量复苏 administration of an initial fluid bolus of 20 mL/kg prior to to v
14、asopressor therapy initiation and achievement of a central venous pressure of 8 mm Hg within 6 h after the onset of therapy with vasopressors Conservative late fluid management (CLFM) 后期限制性液体管理 even-to-negative fluid balance measured on at least 2 consecutive days during the first 7 days after septi
15、c shock onset,何谓“限制性容量管理” （conservative or restricted fluid management）,维持每日液体进出量基本或(尽可能)负平衡 Daily even-to-negative fluid balance 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 维持重要器官功能,Fluid may be a friend when appropriately titrated during the resuscitation, or ebb, phase of acute lung injury. However, excess fluid becomes an enemy when it is no longer physiologically needed.,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,