液體復(fù)蘇膠體地位

液體復(fù)蘇膠體地位---170多年前（1832一位蘇格蘭醫(yī)師，發(fā)現(xiàn)了這種通過(guò)靜脈血管把藥液送入人體的治療手段……明膠GELATIN白蛋白ALBUMIN1915WorldWarI1945WorldWarII1960’WarInVietnam右旋糖苷DEXTRAN羥乙基淀粉1943WorldWarII為什么要開(kāi)發(fā)出這些膠體?重癥液體復(fù)蘇的重要性膠體及其作用目前的爭(zhēng)論總結(jié)什么是膠體?膠體（colloid）又稱(chēng)膠狀分散體（colloidaldispersion）是一種均勻混合物，在膠體中含有兩種不同相態(tài)的物質(zhì)，一種分散，另一種連續(xù)。分散的一部分是由微小的粒子或液滴所組成，大小介于1到100納米之間，且?guī)缀醣椴荚谡麄€(gè)連續(xù)相態(tài)中。按分散劑的不同可分為：氣溶膠(霧、煙、云)；固溶膠(水晶、有色玻璃)液溶膠（蛋白溶液，淀粉溶液，肥皂水，人體血液）人體白蛋白的含量與分布細(xì)胞內(nèi)液細(xì)胞外液體液-約占人體體重60%40%組織間液15%血漿5%蛋白質(zhì)在血漿中含量遠(yuǎn)遠(yuǎn)高于組織間液血漿總蛋白含量約為60-80g/L其中，白蛋白含量約為35-50g/L（占血漿總蛋白的60%)2023/1/12Frank-Starling定律(Multi-)OrganFailureCelldystructionbyimbalancebetweenO2-supplyandO2-consumptionO2undersupportO2debtMacrocirculatorydysfunction

COMicrocirculatorydysfunctionWhatelsebesidesvolumerestrictionandexpansion?FluidresuscitationTissueoxygenationCapillaryleakameliorationHemodynamicsClinicaloutocmeRiskofAnaphylaxisEffectoncoagulationEffectonRenalfunctionJean-LouisVincent,MaxHarryWeil,CritCareMed2006;34:1333–1337IntroductionAcutelyillpatientsfrequentlyrequirefluidrepletion.HypovolemiaExternalloss:bleeding,gastrointestinal,urinarytracts,skinInternalloss:extravasationofblood,exudation/transudationoffluidsRelativeHypovolemia:increasesvenouscapacitanceSepsis,drugsVolumerepletionmaybeessentialtorestorecriticallevelsofcardiacoutputandarterialpressure,resultinginmorenormalperfusionofvitalorgansandtissues.Jean-LouisVincent,MaxHarryWeil,CritCareMed2006;34:1333–1337AcutelyillpatientsfrequentlyrequirefluidrepletionHypovolemia:externalloss&internallossRelativeHypovolemia:increasesvenouscapacitanceVolumerepletionmaybeessentialRestorecriticallevelsofcardiacoutputandarterialpressureMorenormalperfusionofvitalorgansandtissuesJean-LouisVincent,MaxHarryWeil,CritCareMed2006;34:1333–1337IntroductionHemorrhage:Benefit/riskoffluidrepletionmustbeassessedBenefitsofdelayedresuscitationLargevolumeoffluidredcelldeficitoxygendeficitPersistenthypovolemiawillresultinMODSFluidrepletionistypicallymoreeffectiveduringhypovolemicstatesbutislesseffectiveinlaterstages.Jean-LouisVincent,MaxHarryWeil,CritCareMed2006;34:1333–1337“fluidchallenge”Jean-LouisVincent,MaxHarryWeil,CritCareMed2006;34:1333–1337DistinguishedfromconventionalfluidadministrationUsuallytocriticalpatientswithcardiorespiratoryfailureThefluidchallengeisreservedforhemodynamicallyunstablepatientsandoffersthreemajoradvantages:Quantitationofthecardiovascularresponseduringvolumeinfusion.Promptcorrectionoffluiddeficits.Minimizingtheriskoffluidoverloadanditspotentiallyadverseeffects,especiallyonthelungs.重癥液體復(fù)蘇的重要性膠體及其作用目前的爭(zhēng)論總結(jié)復(fù)蘇液體種類(lèi)白蛋白血漿?明膠膠體液晶體液林格氏液生理鹽水

右旋糖苷羥乙基淀粉改良明膠HES200/0.5HES130/0.4尿聯(lián)明膠聚明膠肽天然膠體人工膠體高滲鹽液7.5%鹽水+低右晶體液復(fù)蘇？贊成使用晶體液的理由：費(fèi)用低，容易得到對(duì)腎功能保持較好很少產(chǎn)生不良反應(yīng)。這幾種液體都能糾正脫水可糾正低鈉血癥高滲鹽水（HS）擴(kuò)容效率高反對(duì)使用晶體液的理由：平均留駐時(shí)間短（只有45min）液體輸入量大造成血清白蛋白的稀釋?zhuān)獫B透壓降低，間質(zhì)水腫、肺水腫稀釋血中凝血因子降低血小板計(jì)數(shù)和血紅細(xì)胞壓積血液攜氧能力下降，降低組織氧合KoustovaE,StantonK,GushchinV,etal.Trauma2002;52:872-878.RotsteinOD.Trauma2000;49:580-83.LangK,BoldtJ,SuttnerS,etal.

Analg.2001.93:405-409.Theedemaproblemofcrystalloidsiswellknown“Fluidispouredintotheinterstitialspaceonclinicalinformationgainedfromchangesinintravascularspace….…Theend

point,….peripheralorpulmonaryedema”Twigley&Hillman,Anesthesia1985;40:860-871因生存率下降

NHLBI終止高張鹽水治療休克的研究NIH所屬的國(guó)立心肺血液研究所(NHLBI)已經(jīng)終止了一項(xiàng)有關(guān)嚴(yán)重出血導(dǎo)致休克的創(chuàng)傷患者的臨床液體復(fù)蘇干預(yù)試驗(yàn)該試驗(yàn)旨在研究高張鹽水溶液治療此類(lèi)患者療效及安全性試驗(yàn)終止的原因：觀察到高張鹽水治療組患者在到達(dá)醫(yī)院或急診科前病死率顯著升高，盡管高張鹽水組及生理鹽水組患者28天病死率（研究終點(diǎn)）相似

NHLBIHaltsStudyofConcentratedSalineforShockDuetoLackofSurvivalBenefit.AmericanAcademyofEmergencyMedicine

2009-16(3),

MedScapeToday

COPbalanceessentialforbalancedflowacrosscapillary

膠體滲透壓的平衡是毛細(xì)血管的交換的基本因素CrystalloidscannotimpactCOP→Edema

單獨(dú)使用晶體無(wú)法維持膠體滲透壓→水腫ColloidshelptorestoreCOPandreduceCrystalloidload膠體液有助于恢復(fù)膠體滲透壓和減少晶體負(fù)荷

Artery

(Arteriole)動(dòng)脈,小動(dòng)脈Vein

(Venule)靜脈,小靜脈PlasmaProtein

ColloidOsmoticPressure膠體滲透壓22mmHg簡(jiǎn)化Starling定律HydrostaticPressure靜水壓32mmHgHydrostaticPressure靜水壓12mmHgTissueFluid組織液HypovolemiaEdema,organdamage低血容量水腫,器官損傷膠體滲透壓膠體液的作用容量作用：維持血流動(dòng)力學(xué)穩(wěn)定維持血漿膠體滲透壓改善微循環(huán)／改善組織細(xì)胞氧供

非容量作用：改善CLS改善炎性反應(yīng)物質(zhì)結(jié)合和轉(zhuǎn)運(yùn)抗氧化作用……(colloid)151consecutively

majortraumapatientsWilliamC.Shoemaker

OutcomePredictionofEmergencyPatientsbyNoninvasiveHemodynamicMonitoringChest.2001;120:528-537WilliamC.Shoemaker

OutcomePredictionofEmergencyPatientsbyNoninvasiveHemodynamicMonitoringChest.2001;120:528-537Hemodynamcs（crystalloid）:151consecutively

majortraumapatientsNormalSubstanceP-1minlaterStudyofCapillaryLeakDirect:ScanningEM:normalendothelialcelljunctionDonaldMcDonald1999Crit

CareMed2006;34:1775–1782白蛋白增加血漿中抗氧化劑硫醇含量GregoryJ.etc.CritCareMed.2004;32:755-759

白蛋白增加血漿中抗氧化劑含量GregoryJ.etc.CritCareMed.2004;32:755-759

TheSAFEStudy

Alb:salinedeaths726:729(RR0.99)SimilarneworganfailuresICULOSHospitalLOSVentilatordurationRRTConclusion:OutcomewithalbumininICUnodifferentfromSalineQ:Doesthismeancrystalloidsandcolloidsarethesame?Doesthismeanallcolloidsaresame?Finferetal,NEJM2004;350:2247-56重癥液體復(fù)蘇的重要性膠體及其作用目前的討論總結(jié)膠體液復(fù)蘇并無(wú)優(yōu)勢(shì)------薈萃分析Objective:theeffectonmortalityofresuscitationwithcolloidcomparedwithcrystalloids.Design:Systematicreviewofrandomisedcontrolledtrialsofresuscitationwithcolloidscomparedwithcrystalloidsforcriticallyillpatients;Subjects:37randomisedcontrolledtrialswereeligible:

26uncompoundedtrialsthatcomparedcolloidswithcrystalloids(n=1622),

10trialsthatcomparedcolloidinhypertoniccrystalloidwithisotoniccrystalloid(n=1422)

andonetrialthatcomparedcolloidinisotoniccrystalloidwithhypertoniccrystalloid(n=38).SchierhoutG,RobertsI.Fluidresuscitationwithcolloidor

crystalloidsolutionsincriticallyillpatients:asystematic

reviewofrandomisedtrials.BMJ

1998;316:961-4.Conclusions:Thissystematicreviewdoesnotsupportthecontinueduseofcolloidsforvolumereplacementincriticallyillpatients.Cochrane

Report（2008）ObjectivesToassesstheeffectsofcolloidscomparedtocrystalloidsforfluidresuscitationincriticallyillpatients.Mainresults:identified63eligibletrials,55ofthesepresentedmortalitydata.Colloidscomparedtocrystalloids?Albumin-23trialsreporteddataonmortality,includingatotalof7,754patients.Thepooledrelative

risk(RR)was1.01(95%confidenceinterval[95%CI]0.92to1.10).Whenthetrialwithpoorqualityallocation

concealmentwasexcluded,pooledRRwas1.00(95%CI0.91to1.09).?Hydroxyethylstarch-16trialscomparedhydroxyethylstarchwithcrystalloids,n=637patients.ThepooledRRwas1.05(95%

CI0.63to1.75).?Modifiedgelatin-11trialscomparedmodifiedgelatinwithcrystalloid,n=506patients.ThepooledRRwas0.91(95%CI0.49to1.72).?Dextran-ninetrialscompareddextranwithacrystalloid,n=834patients.ThepooledRRwas1.24(95%CI0.94to1.65).?Eighttrialscompareddextraninhypertoniccrystalloidwithisotoniccrystalloid,including1,283randomisedparticipants.Pooled

RRwas0.88(95%CI0.74to1.05).PerelP,RobertsI,Colloidsversuscrystalloidsforfluidresuscitationincriticallyillpatients(Review).TheCochraneLibrary2008,Issue3Authors’conclusions：ThereisnoevidencefromRCTsthatresuscitationwithcolloidsreducestheriskofdeath,comparedtoresuscitationwithcrystalloids,

inpatientswith

trauma,burnsorfollowingsurgery.Cochrane

Report（2008）Ascolloidsarenotassociatedwithanimprovementinsurvival,andastheyare

moreexpensivethancrystalloids,itishardtoseehowtheircontinueduseinthesepatientscanbejustifiedoutsidethecontextofRCTs.PerelP,RobertsI,Colloidsversuscrystalloidsforfluidresuscitationincriticallyillpatients(Review).TheCochraneLibrary2008,Issue3注：Cochrane是國(guó)際最大的循證醫(yī)學(xué)試驗(yàn)的協(xié)作網(wǎng)，以已故英國(guó)內(nèi)科醫(yī)師和著名流行病學(xué)家Archie

Cochrane的名字命名膠體，ICU用，還是不用？FluidChallenge

500-100mlcristalloids300-500mlcolloidsover30mincontrolCVPorPAOPandreducespeed/volumeaccordingly

Grade1DSurvivingSepsisCampaign:Internationalguidelinesfor

managementofseveresepsisandsepticshock:2008CritCareMed2008Vol.36,No.1Figure.Differences(inpercentagefrombaseline)oftissueoxygentension(ptio2)inthetwovolumegroupsKatrinLang,JoachimBoldt,StefanSuttner,etal.

ColloidsVersusCrystalloidsandTissueOxygenTensioninPatientsUndergoingMajorAbdominalSurgery.AnesthAnalg2001;93:405–9白蛋白對(duì)于重癥患者結(jié)論：白蛋白可以顯著降低重癥病例整體并發(fā)癥的發(fā)生（危險(xiǎn)比:0.92;可信區(qū)間:0.86-0.98)；且并發(fā)癥的發(fā)生率與白蛋白的使用劑量顯著相關(guān)（p=0.002)(Albumin-B-004)Vincent,Jean-Louis,Navickis,RobertaJ.Wilkes,MahlonM.

Morbidityinhospitalizedpatientsreceivinghumanalbumin:Ameta-analysisofrandomized,controlledtrials*

CritCareMed2004;32(10):2029-2038膠體：我們關(guān)心的組織氧代謝？SHOCK,2006

Vol.25,No.2,pp.103Y116 SchortgenetcollLancet2001,357,911SurvivorsHEAorgelatineforSevereSepsis?Resuscitation:selectionofFluidCrystalloidsorColloidscanbeusedFluidchallengeswithcolloidsallowformorerapidcompletionofchallenge.Crystalloid:Physiologic(0.9%)saltsolution(saline)MayincreaseserumchlorideconcentrationsBalancedsaltsolutions(Ringer’slactate/Hartmann’ssolution)Mildlyhypotonic,mayexacerbatecerebraledemaJean-LouisVincent,MaxHarryWeil,CritCareMed2006;34:1333–1337Resuscitation:selectionofFluidSAFEstudy:albuminvscrystalloidsolutionMortalityratewasidenticalHypoalbuminemiaisassociatedwithhighermorbidityVincentJLetal,AnnSurg