液体复苏--胶体的地位课件.ppt

1、液体复苏-胶体的地位中山大学 附属第一医院 重症医学科管向东明胶明胶GELATINGELATIN白蛋白白蛋白ALBUMINALBUMIN19151915World World War IWar I19451945World War IIWorld War II19601960War In Vietnam War In Vietnam 右旋糖苷右旋糖苷DEXTRANDEXTRAN羟乙基淀粉羟乙基淀粉19431943World War IIWorld War II为什么要开发出这些胶体为什么要开发出这些胶体? ? 重症液体复苏的重要性 胶体及其作用 目前的争论 总结什么是胶体? 胶体（colloi

2、d）又称胶状分散体（colloidal dispersion） 是一种均匀混合物，在胶体中含有两种不同相态的物质，一种分散，另一种连续。分散的一部分是由微小的粒子或液滴所组成，大小介于1到100纳米之间，且几乎遍布在整个连续相态中。 按分散剂的不同可分为： 气溶胶(雾、烟、云)； 固溶胶(水晶、有色玻璃) 液溶胶（蛋白溶液，淀粉溶液，肥皂水，人体血液）细胞内液细胞外液体液-约占人体体重60%40%组织间液15%血浆5%蛋白质在血浆中含量远远高于组织间液血浆总蛋白含量约为60-80g/L其中，白蛋白含量约为35-50g/L（占血浆总蛋白的60%)2022-6-22Frank-Starling 定

3、律定律 COWhat else besides volume restriction and expansion?Fluid resuscitationTissue oxygenationCapillary leak ameliorationHemodynamicsClinical outocmeRisk of AnaphylaxisEffect on coagulationEffect on Renal functionJean-Louis Vincent, Max Harry Weil, Crit Care Med 2006; 34:13331337Introduction Acutely

4、 ill patients frequently require fluid repletion. Hypovolemia External loss: bleeding, gastrointestinal, urinary tracts, skin Internal loss: extravasation of blood, exudation / transudation of fluids Relative Hypovolemia: increases venous capacitance Sepsis, drugs Volume repletion may be essential t

5、o restore critical levels of cardiac output and arterial pressure, resulting in more normal perfusion of vital organs and tissues.Jean-Louis Vincent, Max Harry Weil, Crit Care Med 2006; 34:13331337 Acutely ill patients frequently require fluid repletion Hypovolemia: external loss & internal loss Rel

6、ative Hypovolemia: increases venous capacitance Volume repletion may be essential Jean-Louis Vincent, Max Harry Weil, Crit Care Med 2006; 34:13331337Introduction: Benefit / risk of fluid repletion must be assessed Benefits of delayed resuscitation Large volume of fluid red cell deficit oxygen defici

7、t Persistent hypovolemia will result in MODSJean-Louis Vincent, Max Harry Weil, Crit Care Med 2006; 34:13331337Jean-Louis Vincent, Max Harry Weil, Crit Care Med 2006; 34:13331337Distinguished from conventional fluid administrationUsually to critical patients with cardiorespiratory failureThe fluid c

8、hallenge is reserved for patients and offers three major advantages: 重症液体复苏的重要性 胶体及其作用 目前的争论 总结复苏液体种类复苏液体种类白蛋白白蛋白血浆血浆? ?明胶明胶胶体液胶体液晶体液晶体液林格氏液林格氏液生理盐水生理盐水 右旋糖苷右旋糖苷羟乙基淀粉羟乙基淀粉改良明胶改良明胶HES200/0.5HES130/0.4尿联明胶尿联明胶聚明胶肽聚明胶肽天然胶体天然胶体人工胶体人工胶体高渗盐高渗盐液液7.5%盐水盐水+低右低右晶体液复苏？z赞成使用晶体液的理由：z费用低，容易得到z对肾功能保持较好z很少产生不良反应。这几

9、种液体都能纠正脱水z可纠正低钠血症z高渗盐水（HS）扩容效率高z反对使用晶体液的理由：z平均留驻时间短（只有45min）z液体输入量大z造成血清白蛋白的稀释，血渗透压降低，间质水肿、肺水肿z稀释血中凝血因子z降低血小板计数和血红细胞压积z血液携氧能力下降，降低组织氧合Koustova E, Stanton K, Gushchin V, et al. Trauma 2002;52:872-878.Rotstein OD. Trauma 2000;49:580-83.Lang K, Boldt J, Suttner S, et al. Analg.2001.93:405-409.The edema

10、 problem of crystalloids The edema problem of crystalloids is well knownis well knownu“Fluid is poured into the “Fluid is poured into the interstitial space on clinical interstitial space on clinical information gained from changes information gained from changes in intravascular space.in intravascu

11、lar space.uThe endThe end point,.peripheral point,.peripheral or pulmonary edema”or pulmonary edema”Twigley & Hillman,Twigley & Hillman, Anesthesia Anesthesia 1985;40:860-871 1985;40:860-871因生存率下降NHLBI 终止高张盐水治疗休克的研究NIH所属的国立心肺血液研究所(NHLBI)已经终止了一项有关严重出血导致休克的创伤患者的临床液体复苏干预试验该试验旨在研究高张盐水溶液治疗此类患者疗效及安全性试验终止的

12、原因：观察到高张盐水治疗组患者在到达医院或急诊科前病死率显著升高，尽管高张盐水组及生理盐水组患者28天病死率（研究终点）相似 NHLBI Halts Study of Concentrated Saline for Shock Due to Lack of Survival Benefit.American Academy of Emergency Medicine 2009 - 16 (3), MedScape Today Colloids help to restore COP and reduce Crystalloid load胶体液有助于恢复胶体渗透压和减少晶体负荷胶体液有助于恢复胶

13、体渗透压和减少晶体负荷 Artery (Arteriole)动脉,小动脉Vein (Venule)静脉,小静脉Plasma Protein Colloid Osmotic Pressure胶体渗透压22 mm Hg简化简化Starling定律定律Hydrostatic Pressure静水压32 mm HgHydrostatic Pressure静水压12 mm HgTissue Fluid组织液Hypovolemia Edema, organ damage低低血容量血容量 水肿水肿, 器官损伤器官损伤胶体渗透压胶体液的作用(colloid)151 consecutivelymajor tra

14、uma patients William C. ShoemakerOutcome Prediction of Emergency Patients by Noninvasive Hemodynamic Monitoring Chest. 2001;120:528-537 William C. ShoemakerOutcome Prediction of Emergency Patients by Noninvasive Hemodynamic Monitoring Chest. 2001;120:528-537 Hemodynamcs（ crystalloid ）: 151 consecuti

15、velymajor trauma patientsNormalSubstance P- 1 min laterStudy of Capillary LeakCrit Care Med 2006; 34:17751782白蛋白增加血浆中抗氧化剂硫醇含量Gregory J. etc. Crit Care Med. 2004;32:755-759 白蛋白增加血浆中抗氧化剂含量Gregory J. etc. Crit Care Med. 2004;32:755-759 The SAFE Study Alb: saline deaths 726:729 (RR 0.99) Similar new org

16、an failures ICU LOS Hospital LOS Ventilator duration RRT Conclusion: Outcome with albumin in ICU no different from SalineQ: Does this mean crystalloids and colloids are the same? Does this mean all colloids are same?Finfer et al, NEJM 2004;350:2247-56 重症液体复苏的重要性 胶体及其作用 目前的讨论 总结胶体液复苏并无优势-荟萃分析 Objecti

17、ve: the effect on mortality of resuscitation with colloid compared with crystalloids. Design: Systematic review of randomised controlled trials of resuscitation with colloids compared with crystalloids for critically ill patients; Subjects: 37 randomised controlled trials were eligible: 26 uncompoun

18、ded trials that compared colloids with crystalloids (n=1622), 10 trials that compared colloid in hypertonic crystalloid with isotonic crystalloid (n=1422) and one trial that compared colloid in isotonic crystalloid with hypertonic crystalloid (n=38).Schierhout G, Roberts I. Fluid resuscitation with

19、colloid or crystalloid solutions in critically ill patients: a systematic review of randomised trials. BMJ 1998;316:9614.Conclusions: This systematic review does not support the continued use of colloids for volume replacement in critically ill patients.Cochrane Report（2008）ObjectivesTo assess the e

20、ffects of colloids compared to crystalloids for fluid resuscitation in critically ill patients.Main results: identified 63 eligible trials, 55 of these presented mortality data.Colloids compared to crystalloids Albumin - 23 trials reported data on mortality, including a total of 7,754 patients. The

21、pooled relative risk (RR) was 1.01 (95% confidence interval 95% CI 0.92 to 1.10). When the trial with poor quality allocation concealment was excluded, pooled RR was 1.00 (95% CI 0.91 to 1.09). Hydroxyethyl starch - 16 trials compared hydroxyethyl starch with crystalloids, n = 637 patients. The pool

22、ed RR was 1.05 (95% CI 0.63 to 1.75). Modified gelatin - 11 trials compared modified gelatin with crystalloid, n = 506 patients. The pooled RR was 0.91 (95% CI 0.49to 1.72). Dextran - nine trials compared dextran with a crystalloid, n = 834 patients. The pooled RR was 1.24 (95% CI 0.94 to 1.65). Eig

23、ht trials compared dextran in hypertonic crystalloid with isotonic crystalloid, including 1,283 randomised participants. Pooled RR was 0.88 (95% CI 0.74 to 1.05).Perel P, Roberts I, Colloids versus crystalloids for fluid resuscitation in criticallyill patients (Review). The Cochrane Library 2008, Is

24、sue 3Authors conclusions：There is no evidence from RCTs that resuscitation with colloids reduces the risk of death, compared to resuscitation with crystalloids, in patients with trauma, burns or following surgery. Cochrane Report（2008）As colloids are not associated with an improvement in survival, a

25、nd as they are more expensive than crystalloids, it is hard to see how their continued use in these patients can be justified outside the context of RCTs.Perel P, Roberts I, Colloids versus crystalloids for fluid resuscitation in criticallyill patients (Review). The Cochrane Library 2008, Issue 3注：C

26、ochrane是国际最大的循证医学试验的协作网，以已故英国内科医师和著名流行病学家Archie Cochrane的名字命名胶体，ICU用，还是不用？Fluid Challengep 500-100 ml cristalloidsp 300-500 ml colloidsp over 30 minp control CVP or PAOPand reduce speed/volume accordingly Grade 1DSurviving Sepsis Campaign: International guidelines for management of severe sepsis and

27、 septic shock: 2008Crit Care Med 2008 Vol. 36, No. 1Figure. Differences (in percentage from baseline) of tissue oxygentension (ptio2) in the two volume groupsKatrin Lang, Joachim Boldt, Stefan Suttner, et al. Colloids VersusCrystalloids and Tissue Oxygen Tension in Patients Undergoing Major Abdomina

28、l Surgery. Anesth Analg 2001;93:4059白蛋白对于重症患者接受白蛋白治疗的重症患者的并发症接受白蛋白治疗的重症患者的并发症:一项荟萃分析一项荟萃分析( Albumin-B-004) Vincent, Jean-Louis, Navickis, Roberta J. Wilkes, Mahlon M. Morbidity in hospitalized patients receiving human albumin: A meta-analysis of randomized, controlled trials * Crit Care Med 2004;32(

29、10):2029-2038胶体：我们关心的组织氧代谢？SHOCK, 2006 Vol. 25, No. 2, pp. 103Y116 Schortgen et coll Lancet 2001 , 357 , 911SurvivorsHEA or gelatine for Severe Sepsis ?Resuscitation:selection of Fluid Crystalloids or Colloids can be used Fluid challenges with colloids allow for more rapid completion of challenge. C

30、rystalloid: Physiologic (0.9%) salt solution (saline) May increase serum chloride concentrations Balanced salt solutions (Ringers lactate / Hartmanns solution) Mildly hypotonic, may exacerbate cerebral edemaJean-Louis Vincent, Max Harry Weil, Crit Care Med 2006; 34:13331337Resuscitation: selection o

31、f Fluid SAFE study: albumin vs crystalloid solution Mortality rate was identical Hypoalbuminemia is associated with higher morbidity Vincent JL et al, Ann Surg 2003; 237:319334: meta-analysis Albumin administration may reduce complications in critically ill patients SAFE trial: Improved survival wit

32、h albumin in patients with sepsis who are hypoalbuminemia (relative risk of death, 0.87; 95% CI, 0.74 1.02; p 0.06) Albumin may be beneficial in this subset of critically ill patientsJean-Louis Vincent, Max Harry Weil, Crit Care Med 2006; 34:13331337Resuscitation: selection of Fluid Synthetic colloi

33、d solution: Hydroxyethyl starch solutions: Less expensive, adverse effects on blood clotting Gelatins: Smaller MW, less effective plasma expanders, low costJean-Louis Vincent, Max Harry Weil, Crit Care Med 2006; 34:13331337Resuscitation: selection of Fluid No intravenous fluid solution that is ideal

34、 in all clinical settings No secure data support a preference for one over another The choice is best made contingent on: the underlying disease the type of fluid that has been lost the severity of circulatory failure the serum albumin concentration of the patient the risk of bleeding.Jean-Louis Vincent, Max Harry Weil, Crit Care Med 2006; 34:13331337 重症液体复苏的重要性 胶体及其作用 目前的争论 总结总 结 重症病人的液体复苏，是最重要/最早的复苏手段之一 容量替代、血流动力学稳定、组织氧合均是临床液体复苏的重要目标 液体选择种类很多，无论何种液体（晶胶体），从使用开始，需要考虑不良作用 胶体液的使用，要同时考虑容量以外问题 目前，晶体或胶体复苏孰优孰劣，需要更有说服力的循证医学证据支持谢谢！