关注危重病人液体平衡(定稿).ppt

关注危重病人液体平衡关注危重病人液体平衡徐颖鹤徐颖鹤目录目录EGDT提高抢救成功率提高抢救成功率液体超负荷增加危重病人死亡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？监测能准确指导液体复苏吗？白蛋白用于液体复苏新观点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 demandChest1992;101:1644.Early Goal-Directed Therapy in the Treatment of Severe Sepsis and Septic ShockRiversE,NguyenB,HavstadS,etal.Earlygoal-directedtherapyinthetreatmentofseveresepsisandsepticshock.NEJM2001;345:1368.Study purpose:to evaluate the efficacy of early goal-directed therapy in patients presenting to an emergency department with severe sepsis or septic shock(prior to ICU admission)Study design:prospective,randomized controlled,partially blinded,single center trialPatientrandomizedN=263EarlygoaldirectedtherapyN=130StandardtherapyN=133CVP8-12mmHgMAP65mmHgUrine Output0.5ml/kg/hrCVP8-12mmHgMAP65mmHgUrine Output0.5ml/kg/hrScvO270%SaO293%Hct 30%AntibioticsgivenatdiscretionoftreatingcliniciansAssoonaspossibleMean6.2hrsICUMDsblindedtostudytreatmentNEJM2001;345:1368-77.Atleast6hoursofEGDTMean8hrsTransfertoICUCVP:centralvenouspressureMAP:meanarterialpressureScvO2:centralvenousoxygensaturationEarly Goal-Directed TherapyNEJM2001;345:1368-77.49.2%33.3%0102030405060Standard Therapy N=133EGDTN=130P=0.01*KeydifferencewasinsuddenCVcollapse,notMODSEarly Goal-Directed Therapy Results:28 Day MortalitySuddenCVCollapseMODS21%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监测能准确指导液体复苏吗？复苏吗？Objective:A systematic review of the literature to determine the following:(1)the relationship between CVP and blood volume,(2)the ability of CVP to predict fluid responsiveness,(3)the ability of the change in CVP(CVP)to predict fluid responsiveness.The pooled correlation coefficient between theCVP and measured blood volume was 0.16(95%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 0.182、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 8.7-2.3mm Hg in the responders,as compared to 9.7-2.2mm Hg in nonresponders(not signficant;p 0.3).结论结论1、CVP与血容量之间相关性很低与血容量之间相关性很低2、CVP或者或者CVP没有能力判定补液对没有能力判定补液对血流动力学的影响血流动力学的影响3、CVP不应该用于医生决策液体治疗不应该用于医生决策液体治疗Fluid Resuscitation in Septic shockA Positive Fluid Balance and Elevated Central Venous Pressure Are Associated With Increased Mortality回归性分析回归性分析The Vasopressin in Septic Shock Trial(VASST)study 778为感染性休克患者为感染性休克患者研究目的是确定研究目的是确定CVP、液体平衡与死亡、液体平衡与死亡率关系率关系CritCareMed.2011;39(2):259-6512h液体平衡与CVP有关联，24小时就没有关联CVP GroupNet Fluid Balancep SurvivorsNonsurvivorsAll Patients3444(18615984)mL4429(25376560)mL.001CVP 12 mm Hg3975(23876614)mL5237(31407773)mL.001Stop filling patients against central venous pressure,please!*CritCareMed2011Vol.39,No.2Lees N,Hamilton M,Rhodes A:Clinical review:Goal-directed therapy in high risk surgicalpatients.Crit Care 2009;13:231修正的修正的EGDT试验试验u1.镇静镇痛u2.液体反应性：CVP动态变化；对于正压通气患者SVV/PPVu3.滴定MAP7585mmHgu4.P(cv-a)CO2u5.血管活性药撤离试验血管活性药血管活性药物撤离试验物撤离试验液体超负荷，我们要重视液体超负荷，我们要重视的问题！的问题！Payen S,etal,for the Sepsis Occurrence in Acutely Ill Patients(SOAP)Investigators:A positive fluid balance 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 shockA Positive Fluid Balance and Elevated Central Venous Pressure Are Associated With Increased Mortality回归性分析回归性分析The Vasopressin in Septic Shock Trial(VASST)study 778为感染性休克患者为感染性休克患者研究目的是确定研究目的是确定CVP、液体平衡与死亡、液体平衡与死亡率关系率关系CritCareMed.2011;39(2):259-6512h液体正平衡4.23.8L第四天液体正平衡118.9LQuartile 1(Dry)Quartile 2Quartile 3Quartile 4(Wet)12hrs Intake,mL2900(20503900)4520(37005450)6110(53307360)10,100(843012,100)Output,mL2200(11003920)1590(9602560)1180(6002070)1260(6002400)Balance,mL710(1321480)2880(25103300)4900(42905530)8150(711010,100)Day4 Intake,mL16,100(12,80019700)18,500(15,70022,500)22,800(19,70026,700)30,600(26,20036,000)Output,mL14,600(11,50020100)11,000(821014,500)9960(694012,900)8350(510012,300)Balance,mL1560(7233210)8120(62109090)13,000(11,80014,700)20,500(17,70024,500)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CVP GroupNet Fluid Balancep SurvivorsNonsurvivorsAll Patients3444(18615984)mL4429(25376560)mL.001CVP 12 mm Hg3975(23876614)mL5237(31407773)mL.001结论：液体超负荷增加死亡风险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：入院多因素回归分析表明：入院72小时液体平衡小时液体平衡时独立的结果预测指标：没增加时独立的结果预测指标：没增加1升的液体积升的液体积聚，死亡风险增加聚，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.方法方法:Fluid overload was 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 20096