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EarlyGoal-DirectedTherapy(EGDT):involvesadjustmentsofcardiacpreload,afterload,andcontractilitytobalanceO2deliverywithO2demandChest1992;101:1644..EarlyGoal-DirectedTherapyintheTreatmentofSevereSepsisandSepticShockRiversE,NguyenB,HavstadS,etal.Earlygoal-directedtherapyinthetreatmentofseveresepsisandsepticshock.NEJM2001;345:1368.Studypurpose:toevaluatetheefficacyofearlygoal-directedtherapyinpatientspresentingtoanemergencydepartmentwithseveresepsisorsepticshock(priortoICUadmission)Studydesign:prospective,randomizedcontrolled,partiallyblinded,singlecentertrialPatientrandomizedN=263EarlygoaldirectedtherapyN=130StandardtherapyN=133CVP>8-12mmHgMAP>65mmHgUrineOutput>0.5ml/kg/hrCVP>8-12mmHgMAP>65mmHgUrineOutput>0.5ml/kg/hrScvO2>70%SaO2>93%Hct>30%AntibioticsgivenatdiscretionoftreatingcliniciansAssoonaspossibleMean6.2hrsICUMDsblindedtostudytreatmentNEJM2001;345:1368-77.Atleast6hoursofEGDTMean8hrsTransfertoICUCVP:centralvenouspressureMAP:meanarterialpressureScvO2:centralvenousoxygensaturationEarlyGoal-DirectedTherapyNEJM2001;345:1368-77.49.2%33.3%0102030405060StandardTherapyN=133EGDTN=130P=0.01**KeydifferencewasinsuddenCVcollapse,notMODSEarlyGoal-DirectedTherapyResults:28DayMortalitySuddenCVCollapseMODS21%vs10%p=0.0222%vs16%P=0.27NEJM2001;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:Asystematicreviewoftheliteraturetodeterminethefollowing:(1)therelationshipbetweenCVPandbloodvolume,(2)theabilityofCVPtopredictfluidresponsiveness,(3)theabilityofthechangeinCVP(CVP)topredictfluidresponsiveness.ThepooledcorrelationcoefficientbetweentheCVPandmeasuredbloodvolumewas0.16(95%CI,0.03to0.28;r=0.02).1、ThepooledcorrelationcoefficientbetweenbaselineCVPandchangeinstrokeindex/cardiacindexwas0.182、ThepooledareaundertheROCcurvewas0.563、ThepooledcorrelationbetweenCVPandchangeinstrokeindex/cardiacindexwas0.114、ThebaselineCVPwas...
