目標導(dǎo)向的液體治療

1、目標導(dǎo)向液體治療Goal-directedfluidtherapy復(fù)旦大學(xué)附屬中山醫(yī)院麻醉科薛張綱Moore(1959)外科應(yīng)激一應(yīng)激一水鈉創(chuàng)傷反應(yīng)激素T潴留圍手術(shù)期應(yīng)當限制液體輸入Shires(1961)大手術(shù)液體 轉(zhuǎn)移Q 用晶體液補充第三間隙液體的丟失.生理需要量：晶體液.術(shù)前液體喪失量：晶體液.液體再分布：晶體液.麻醉后血管擴張：晶體液或（和）膠體液.術(shù)中失血：晶體液、膠體液和血制品是麻醉科醫(yī)生輸液的準則，但合理嗎?主張限制輸液者認為避免大量的液體進入組織間隙降低心肺并發(fā)癥及傷口感染發(fā)生率加速胃腸道功能的恢復(fù)縮短住院時間降低并發(fā)癥的發(fā)生率與死亡率LoboDN,etal.Lancet200

2、2;359:181218JoshiGP.AnesthAnalg.2005;101:601BrandstrupB.AnnSurg.2003;238:641648保證有效的組織灌注術(shù)中循環(huán)穩(wěn)定術(shù)后惡心、嘔吐減少術(shù)后康復(fù)加速HolteK,etal.AnnSurgy2004;240:892AHSZfetal.Anaesthesia92003,58,775-803支持開放輸液者的觀點r48例ZS4L2級病人，接受AC手術(shù)分成開放輸液和限制輸液組開放40nil/kgLR限制15ml/kgLR觀察指標今呼吸、運動能力、心血管激素反應(yīng)、疼痛、惡心和嘔吐、康復(fù)和住院時間HolteK,etal.LiberalVe

3、rsusRestrictiveFluidAdministrationtoImproveRecoveryAfterLaparoscopicCholecystectomy,ARandomized,Double-BlindStudy.AnnalsofSurgery,2004,240(5):892-899.TABLE4.DischargeDataandDataFromtheWard15mL/kgLR40mL/kgLRPValueFluidintake6ampreoperatively175(0-175)175(0-175)0.98Oralfluidintake(0-4hours)537.50(175-

4、1175)725(175-1500)0.04Fulfillingdischargecriteria(PADDSn9)onthedayofsurgery16/823/10.01Dischargeondavofsurerv(fromootentiallvdischargeableDatients)15/2321/220.02Morphineconsumption(4hpostoperatively)Patientsrequiring640.51Totaldose(mg)0(0-30)0(0-30)0.42Ondansetron(4hpostoperatively)Patientsrequiring

5、101.00Totaldose(mg)4(OY)0(0-0)0.32開放輸液組術(shù)后進食早，手術(shù)當天符合出院標準和出院人數(shù)明顯大于限制輸液組HolteK,etal.LiberalVersusRestrictiveFluidAdministrationtoImproveRecoveryAfterLaparoscopicCholecystectomy,ARandomized,Double-BlindStudy.AnnalsofSurgery,240(5):892-899.3.75(D? quad (TUIEDEBd(號)P2 Pl 3M開放輸液組術(shù)后肺功能和運動能力都明顯優(yōu)于限制輸液組HolteK,

6、etal.LiberalVersusRestrictiveFluidAdministrationtoImproveRecoveryAfterLaparoscopicCholecystectomy,ARandomized,Double-BlindStudy.AnnalsofSurgery,2004,240(5):892-899.然而，術(shù)中輸液過多可以導(dǎo)致組織水腫臨床液體治療的最終目的是今術(shù)中液體治療的最終目標是避免輸液不足引起的隱匿性低血容量和組織低灌注，及輸液過多引起的心功能不全和外周組織水腫今必須保證滿意的血容量和適宜的麻醉深度，對抗手術(shù)創(chuàng)傷可能引起的損害，保證組織灌注滿意，器官功能正常Im

7、portantperioperativeaim:AvoidanceofedemaExample:Abdominalhypertension主張限制輸液者的觀點（1）20例正常的病人，行大腸手術(shù)分組今標準液體輸注（231上入S2L5%GS）今限制液體輸注（W2L,0.5LNS,L5L5%GS）比較終點今體重、尿量、電解質(zhì)、胃腸動力和其它并發(fā)癥LoboDN,etaLEffectofsaltandwaterbalanceonrecoveryofgastrointestinalfunctionafterelectivecolonicresection:arandomisedcontrolledtria

8、l.Lancet2002;359:1812-1854321012(皇1S一MU一Huw。體重靜脈補液量(IE)Hp5=snou&lu-jolunoAnE)indu一prl三S01尿鈉排出量0(-OIUUJ)lndnoErl-posXJO3U一nStandardgroupRestrictedgroup(n=10)(n二坳P(guān)eripheraloedema70Hyponatraemia(NaW1B。mmol/L),40expressedaspatient-daysHypokalaemia(KC3-5mmol/L).21expressedaspatient-daysVomitingonday430Co

9、nfusionafterday130Woundinfection10Respiratoryinfection20Readmissionwithin30days1*0Deathwithin30days1*0Totalnumberofpatientsdeveloping7tItSide-effectsandcomplicationsside-effectsorcomplicationsValuesarenumberofpatients.*Occurredinthesamepatient.Causeofdeath:lymphangitiscarcinomatosiLfp=0-01Fishersexa

10、cttest.Table4:Side-effectsandcomplications兩組并發(fā)癥和30天死亡人數(shù)比較兩組固體和液體食物排空時間比較50005000502211cs81SEA8ud常osssoswdp=0(i)OS-Busldlu。三seBaseqdpnb二-002-50StandardgroupRestrictedgroupStarxiardgroupRestrictedgroup兩組病人終點事件的比較線占一、fl1標準組1限制組1差異P值首次肛門排氣（天）4.0(4.0-5.0)3.0(2.0-3.0)0.001首次排便（天）6.5(5.8-8.0)4.0(3.0-4.0)0.

11、001停止靜脈輸液（天）6.0(4.8-6.3)4.0(3.8-4.0)0.001恢復(fù)固體食物（天）6.5(5.5-7.0)4.0(4.0-4.3)0.002術(shù)后住院時間（天）9.0(7.8-14.3)6.0(5.0-7.0)0.001Anesthesiology2(X)5;103:25-322(X)5AmericanSocietyofAiwsdiesiologists,Inc.LippincottWilliams&Wilkins,Inc.EffectofIntraoperativeFluidManagementonOutcome(tfterIntraabdominalSurgeryVadim

12、Nisanevich,M.D.；ItamarFelsenstein,GidonAlmogy,CharlesWeissman,M.D.,豐SharonEinav,M.D.,IditMatot,MD|TotalVolumeofFluidAdministeredRestrictiveLiberalProtocolProtocolGroupGroup(n=75)(n=77) TOC o 1-5 h z Intraoperative3,8781,1701,408946*Postoperativeday112,0124752,170476Postoperativeday21,9855342,052492P

13、ostoperativeday31,8704751,955542PerioperativeComplicationsRestrictiveLiberalProtocolProtocolGroupComplicationsGroup(n=75)(n=77)InfacticusResults:ThenumberofpatientswithcomplicationswaslowerintheRPG(P=0.046).PatientsintheLPGpassedflatusandfecessignificantlylater(flatus,medianrange:43-7daysintheLPGvs.

14、32-7daysintheRPG；P0,001；feces：64-9daysintheLPGvs.43-9daysintheRPG;P0.001),andtheirpostoperativehospitalstaywassignificantlylonger(97-24daysintheLPGvs.86-21daysintheRPG;P=0.01).Sign很icantlylargerincreasesinbodyweightwereobservedintheLPGcomparedwiththeRPG(P0.01).Inthefirst3postoperativedays,hematocrit

15、andalbuminconcentrationsweresignifyicantlyhigherintheRPGcomparedwiththeLPG.1UIPulmonaryemboli00RenalRenaldysfunction00Daathn0Totalnumberofcomplications3217Totalnumberofpatientswith2313*complications主張限制輸液者的觀點（3）病人總數(shù)7例，加入隨機、雙盲對照研究圍術(shù)期液體治療分成限制輸液和常規(guī)輸液組限制輸液組各種并發(fā)癥發(fā)生率降低“心、肺并發(fā)癥7%vs24%“組織愈合并發(fā)癥76%助37%“死亡率Ops4

16、7%結(jié)論：擇期結(jié)直腸手術(shù)圍術(shù)期限制輸液有利BrandstrupB,PottF,etal:EffectsofIntravenousFluidRestrictiononPostoperativeComplications:ComparisonofTwoPerioperativeFluidRegimens.ARandomizedAssessor-BlindedMulticenterTrial.AnnalsofSurgery,2003,238,641648.術(shù)中限制入液量“硬膜外麻醉無液體負荷“沒有第三間隙丟失液的標準替代物“失血替代物一HES1:1術(shù)后引流失液量可以HES術(shù)后根據(jù)體重計算補液量術(shù)后優(yōu)

17、先考慮經(jīng)口補液RSRSRSRSRSRSRS術(shù)后期Day1Day2Day3Day4Day5Day6靜脈補液和體重增加的相關(guān)并發(fā)癥100908070605040302010輸入液體量n=48n=42n=40增加體重n=52n=435.5L2.5kgEndothelialinjuryfollowingvolumeoverloadingJacobM,etal.Anesthesiology.2006;104:1223-31.RehmMetal.Anesthesiology2001;95:849-856.ImpactofDifferentCrystalloidVolumeRegimesonIntestin

18、alAnastomoticStabilityGoranMarjanovic,MD,*ChristianVillain,*EvaJuettner,MD,tAxelzurHausen,MD,PhD,tJensHoeppner,MD,UlrichTheodorHoptfMD,*OliverDrognitz,MD,*andRobertOhermaier,MD*Theauthorsconcludedthatthevolumeoverload陽卬havedeleteriouseffectsonanastomotichealingandpostoperativecomplicationsinGIsurger

19、ypossiblebecauseofamarkedbowelwalledema.Ann. Surg. 2009; 249(2):181-5EditorialFluidOverloadandSurgicalOutcomeAnotherPieceintheJigsawDileepN.Lobo,DM,FRCSThekeytobetterintravenousfluidtherapyistogivetherightamountoftherightfluidattherighttimeandtotryandinaintainthepatientinastateofzerofluidbalanceasmu

20、chaspossibleAvoidanceoffluidoverload,ratherthanfluidrestrictioqseemstobethekeytobetterpostoperativeoutcome.LoboDN.AnnSurg.2009Feb;249(2):186-8圍手術(shù)期液體治療的影響因素及預(yù)后morbidity八procedurecomorbiditiespreop hydrationbowel preparationanaesthesia / neuroaxial blockadeT risk of: organ hypoperfusion SIRS sepsis mu

21、lti organ failureT risk。： oedema ileus PONV pulm complications T cardiac demandshypovolaemianormovolaemiahypervolaemia有關(guān)液體治療的推論液體過量有害液體不足同樣有害猜測往往會誤導(dǎo)臨床醫(yī)生，應(yīng)當評估而不是猜測液體治療應(yīng)采取個體化的原則GoalDirectedFluidTherapy：usingmorepatientdataandfewerassumptions目標導(dǎo)向液體治療100例病人，隨機分成常規(guī)輸液和目標控制輸液組目標控制輸液“經(jīng)食管多普勒監(jiān)測指導(dǎo)術(shù)中補液(FTc,SV)“

22、6%HES以200桃/增加，以達到最佳心排血量進食固體食物的時間分別為47土0.5vs3.。子5天住院時間分別為7士3Vs5于3天術(shù)后需要治療的嚴重尸QVP分別為36%V514%GanTJ,etal:Goal-directedIntraoperativeFluidAdministrationReducesLengthofHospitalStayafterMajorSurgeiy.Anesthesiology2002;97:820-6.使用與以/Mr指導(dǎo)液體輸注FTc-CorrectedFlowTimeSV-StrokeVolumeRandomizedclinicaltrialRandomize

23、dclinicaltrialassessingtheeffectofDoppler-optimizedfluidmanagementonoutcomeafteelectivecolorectalresectionS.E.Noblett1,C.P.Snowden2,B.K.Shenton4andA.F.Horgan3Results:Demographicandsurgicaldetailsweresimilarinthetwogroups.Aorticflowrime,strokevolume,cardiacoutputandcardiacindexduringtheintraoperative

24、periodwerehigherintheinterventiongroup(PMinimally invasive CO/SVyCVPMore invasiveDoppler, TEEWPACath目標導(dǎo)向液體治療經(jīng)食管超聲多普勒今降主動脈校正血流時間(Correctedflowtime,FTc)今心輸出量(CardiacOutput)Ma分析證明今降低圍術(shù)期并發(fā)癥的發(fā)生今縮短住院時間WalshSR,etal.IntJClinPract2008;62:466AbbasSMyetal.Anaesthesia2008;63:44GanTJyAnesthesiology2002;97:820-6目

25、標導(dǎo)向輸液反對者之聲今操作復(fù)雜，代價昂貴今額外地增加了患者的創(chuàng)傷替代經(jīng)食管超聲多普勒fPPV今APCOSWPinskyMR,etal.CritCareMed,2005;33:1119LopesMRyetal.CritCare2007;11:RI00每搏心排血量變異率（SPP）二飛V由脈搏波曲線卞面積確定2機械通氣對動脈血壓的影響是生理學(xué)的基本*r前負荷反應(yīng)性的指標：產(chǎn)生的原因：呼吸對動脈血壓的影響正常范圍今自主呼吸情況下變異的正常范圍5-10%“機械通氣，潮氣量8加冰g8-13%SW預(yù)測心臟對容量負荷的反應(yīng)Theincreaseofpreloadvolumeisequal:AEDV=NEDV2

26、SV2SPP的臨床應(yīng)用S”是一個動態(tài)的參數(shù)，應(yīng)當連續(xù)監(jiān)測S”目前僅適用于機械通氣的病人S能夠預(yù)測心臟對容量負荷的反應(yīng)，其理論依據(jù)是Frank-StarlingcurveBerkenstadtetal,EurJAnaesthesiol17(19):4%2000Reuteretal,EurJ.Anaesthesia17(Suppl19):163,2000Reuteretal,BritishJournalofAnaesthesia88(1)1246,2002CardiacOutputFloTracsensor(arterialcatheter)臨床使用SW指南是否病員需要調(diào)整SV或CO（通過臨床檢查

27、、SKCO或監(jiān)測，乳酸水平和腎功能情況等）是否動脈壓力波形非常準確？（進行沖洗試驗）病員是否存在自主呼吸干擾?潮氣量是否,8mL/kg是否心律規(guī)則？（非房顫心律）可以測定并參考SFV監(jiān)測結(jié)果指導(dǎo)臨床治療圍術(shù)期液體管理流程I外科手術(shù)危險程度評分I常規(guī)監(jiān)測考慮監(jiān)測高齡 ASA 3合并癥手術(shù)范圍創(chuàng)傷急診失血A大量的體液轉(zhuǎn)移啟動液體管理流程氐或SW 13%即秘。2（氐考慮補充液體，靜脈給予正性肌力藥物或縮血管藥物考慮輸注紅細胞、正性肌力藥物或縮血管藥物基礎(chǔ)：補充晶體液57Mz%r,并根據(jù)SKSFT和頻射。2監(jiān)測決定額外補液量FloTracHemodynamicAlgorithmwithSW/APCOD

28、ecreasedCOandBPVolumeResponsive:SVV13%HypovolemiaNORMALRANGESCardiacOutput(CO=HRxSV/1000)=4-8LpmCardiacIndex(CI=CO/BSA)=2.5-4.1LpmStrokeVolume(SV=CO/HRxlOOO)=60-100ml/beatStrokeVolumeVariation(SW=SVmax-SVmin/SVmean)=13%StrokeVolumeIndex(SVCFHRxlOOO)=25-45ml/beatAnesthesiology2009:110:496-504Copyriglir2009,theAmericanSocietyofAnesrtKsiologists.Inc.LippincottWilliams&VGoal-directedColloidAdministrationImprovestheMicrocirculationofHealthyandPerianastomoticColonOliverKimberger,M.D.；MichaelArnberger,M.D.,*SebastianBrandt,M.D.；JanPlock,GisliH.Sigurdsson,M.D.,Ph.D/AndreaKurz,/W.D.,LuziusHil