2022年医学专题—关注危重病人液体平衡(定稿).ppt

关注(gunzh)危重病人液体平衡,徐颖鹤,第一页，共六十一页。,目录(ml),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(jin c)能准确指导液体复苏吗？白蛋白用于液体复苏新观点,第二页，共六十一页。,Early Goal-Directed Therapy(EGDT):involves adjustments of cardiac preload,afterload,and contractility to balance O2 delivery with O2 demand,Chest 1992;101:1644.,第三页，共六十一页。,Early Goal-Directed Therapy in the Treatment of Severe Sepsis 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 septic shock(prior to ICU admission)Study design:prospective,randomized controlled,partially blinded,single center trial,第四页，共六十一页。,CVP 8-12 mm HgMAP 65 mm HgUrine Output 0.5 ml/kg/hr,CVP 8-12 mm HgMAP 65 mm HgUrine Output 0.5 ml/kg/hrScvO2 70%SaO2 93%Hct 30%,Antibiotics given at discretion of treating clinicians,ICU MDs blinded to study treatment,NEJM 2001;345:1368-77.,At least 6 hoursof EGDTMean 8hrs,第五页，共六十一页。,CVP:central venous pressureMAP:mean arterial pressureScvO2:central venous oxygen saturation,Early Goal-Directed Therapy,NEJM 2001;345:1368-77.,第六页，共六十一页。,第七页，共六十一页。,第八页，共六十一页。,49.2%,33.3%,0,10,20,30,40,50,60,Standard Therapy N=133,EGDTN=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,第九页，共六十一页。,质疑(zhy)点,质疑(zhy)点,质疑(zhy)点,第十页，共六十一页。,CVP监测能准确指导液体(yt)复苏吗？,第十一页，共六十一页。,Objective:A systematic review of the 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.,第十二页，共六十一页。,The pooled correlation coefficient between theCVP and measured blood volume was 0.16(95%CI,0.03 to 0.28;r=0.02).,第十三页，共六十一页。,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).,第十四页，共六十一页。,结论(jiln),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(yshng)决策液体治疗,第十五页，共六十一页。,Fluid Resuscitation in Septic shockA Positive Fluid Balance and Elevated Central Venous Pressure Are Associated With Increased Mortality,回归性分析The Vasopressin in Septic Shock Trial(VASST)study 778为感染性休克患者研究(ynji)目的是确定CVP、液体平衡与死亡率关系,Crit Care Med.2011;39(2):259-65,第十六页，共六十一页。,12h液体(yt)平衡与CVP有关联，24小时就没有关联,第十七页，共六十一页。,第十八页，共六十一页。,Stop filling patients against central venous pressure,please!*,Crit Care Med 2011 Vol.39,No.2,第十九页，共六十一页。,Lees N,Hamilton M,Rhodes A:Clinical review:Goal-directed therapy in high risk surgicalpatients.Crit Care 2009;13:231,第二十页，共六十一页。,修正的EGDT试验1.镇静(zhnjng)镇痛2.液体反应性：CVP动态变化；对于正压通气患者SVV/PPV3.滴定MAP7585mmHg4.P(cv-a)CO25.血管活性药撤离试验,第二十一页，共六十一页。,血管活性药物撤离(chl)试验,第二十二页，共六十一页。,液体(yt)超负荷，我们要重视的问题！,第二十三页，共六十一页。,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(jj)在为重病人中经常发生,第二十四页，共六十一页。,Fluid Resuscitation in Septic shockA Positive Fluid Balance and Elevated Central Venous Pressure Are Associated With Increased Mortality,回归性分析The Vasopressin in Septic Shock Trial(VASST)study 778为感染性休克(xik)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,第二十五页，共六十一页。,12h液体(yt)正平衡4.2 3.8 L 第四天液体正平衡11 8.9 L,第二十六页，共六十一页。,第二十七页，共六十一页。,1、2与4相比(xin b)，死亡率下降3与4相比，有下降，但无统计学意义,第二十八页，共六十一页。,结论：液体超负荷增加死亡(swng)风险,第二十九页，共六十一页。,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结果预测指标(zhbio)：没增加1升的液体积聚，死亡风险增加,第三十页，共六十一页。,Fluid accumulation survival and recovery of kidney function in critically ill patients with acute kidney injury.,目的(md):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 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 2009,第三十一页，共六十一页。,618 critically ill patients were examined the effect of fluid overload,第三十二页，共六十一页。,Figure 2.Mortality rate by final fluid accumulation relative to baseline weight and stratified by dialysis status.Reprinted from reference 20,with permission.,第三十三页，共六十一页。,a highly significant correlation was observed between mortality and the proportion of days in which fluid overload was present(P0.0001).结论(jiln)：In patients with acute kidney injury,fluid overload was independently associated with mortality.,第三十四页，共六十一页。,The importance of fluid management