1、感染性休克的液体复苏1 感染性休克的液体复苏 补什么?补多少?补多快?2 2022-12-4Fluid resuscitation of septic shock 2001 EGDT 2004 initial guidelines 2008 updated version guidelines 2010 severe sepsis bundles3 2022-12-4Fluid resuscitation of septic shock 2001 EGDT 2004 initial guidelines 2008 updated version guidelines 2010 severe s
2、epsis bundles 2012 updated Guidelines4 2022-12-4Emanuel Rivers et al.N Engl J Med 2001;345:1368-77In-hospital mortality was 30.5 percent in the group assigned to early goal-directed therapy,as compared with 46.5 percent in the group assigned to standard therapy(P=0.009).5 2022-12-4Emanuel Rivers et
3、al.N Engl J Med 2001;345:1368-776 2022-12-4Emanuel Rivers et al.N Engl J Med 2001;345:1368-777 2022-12-4Emanuel Rivers et al.N Engl J Med 2001;345:1368-778 2022-12-4R.Phillip Dellinger et al.Crit Care Med.2008;36(1):296-327.9 2022-12-4R.Phillip Dellinger et al.Crit Care Med.2008;36(1):296-327.10 202
4、2-12-4Fluid therapy Fluid-resuscitate using crystalloids or colloids.（1B）Target a CVP of 8mmHg（12mmHg if mechanically ventilated）.（1C）Use a fluid challenge technique while associated with a haemodynamic improvement.（1D）R.Phillip Dellinger et al.Crit Care Med.2008;36(1):296-327.11 2022-12-4Fluid ther
5、apy Give fluid challenges of 1000 ml of crystalloids or 300500 ml of colloids over 30min.More rapid and larger volumes may be required in sepsis-induced tissue hypoperfusion.（1D）Rate of fluid administration should be reduced if cardiac filling pressures increase without concurrent hemodynamic improv
6、ement.（1D）R.Phillip Dellinger et al.Crit Care Med.2008;36(1):296-327.12 2022-12-4Levy MM et al.Intensive Care Med.2010;36(2):222-31.13 2022-12-4Sepsis Resuscitation Bundle（first 6hrs）1.Serum lactate measured.2.Blood cultures obtained prior to antibiotic administration.3.From the time of presentation
7、,broad-spectrum antibiotics administered within 3 hours for ED admissions and 1 hour for non-ED ICU admissions.Levy MM et al.Intensive Care Med.2010;36(2):222-31.14 2022-12-4Sepsis Resuscitation Bundle（first 6hrs）4.In the event of hypotension and/or lactate 4 mmol/L(36 mg/dl):a)Deliver an initial mi
8、nimum of 20 ml/kg of crystalloid(or colloid equivalent).b)Apply vasopressors for hypotension not responding to initial fluid resuscitation to maintain mean arterial pressure(MAP)65 mm Hg.Levy MM et al.Intensive Care Med.2010;36(2):222-31.15 2022-12-4Sepsis Resuscitation Bundle（first 6hrs）5.In the ev
9、ent of persistent hypotension despite fluid resuscitation(septic shock)and/or lactate 4 mmol/L(36 mg/dl):a)Achieve central venous pressure(CVP)of 8 mm Hg.b)Achieve central venous oxygen saturation(ScvO2)of 70%.*Levy MM et al.Intensive Care Med.2010;36(2):222-31.16 2022-12-4 1.Low-dose steroids admin
10、istered for septic shock in accordance with a standardized hospital policy.2.Drotrecogin alfa(activated)administered in accordance with a standardized hospital policy.Sepsis Management Bundle（first 24hrs）Levy MM et al.Intensive Care Med.2010;36(2):222-31.17 2022-12-4 3.Glucose control maintained low
11、er limit of normal,but 150 mg/dl(8.3 mmol/L).4.Inspiratory plateau pressures maintained 30 cm H2O for mechanically ventilated patients.Sepsis Management Bundle（first 24hrs）Levy MM et al.Intensive Care Med.2010;36(2):222-31.18 2022-12-4Main results Data from 15,022 subjects at 165 sites were analyzed
12、 to determine the compliance with bundle targets and association with hospital mortality.Levy MM et al.Intensive Care Med.2010;36(2):222-31.19 2022-12-4Main results Compliance with the entire resuscitation bundle increased linearly from 10.9%in the first site quarter to 31.3%by the end of 2 years(P
13、0.4 in patients with severe sepsis or risk of acute kidney injury and suggest not to use 6%HES 130/0.4 or gelatin in these populations.Reinhart K et al.Intensive Care Med.2012;38(3):368-83.45 2022-12-4Recommendations and conclusions We recommend not to use colloids in patients with head injury and n
14、ot to administer gelatins and HES in organ donors.Reinhart K et al.Intensive Care Med.2012;38(3):368-83.46 2022-12-4Recommendations and conclusions We suggest not to use hyperoncotic solutions for fluid resuscitation.Until the results of the ongoing studies(ESM)become available and in the absence of
15、 other RCTs comparing the use of hyperoncotic albumin with other fluid for shock resuscitation,the safety of hyperoncotic albumin remains unclear for the correction of hypoalbuminaemia and for resuscitation in shock.Reinhart K et al.Intensive Care Med.2012;38(3):368-83.47 2022-12-4Recommendations an
16、d conclusions We conclude and recommend that any new colloid should be introduced into clinical practice only after its patient-important safety parameters are establishedReinhart K et al.Intensive Care Med.2012;38(3):368-83.48 2022-12-4Brochard L et al.Am J Respir Crit Care Med.2010;181(10):1128-55
17、.49 2022-12-4Panel recommendations We consider fluid resuscitation with crystalloids to be as effective and safe as fluid resuscitation with hypooncotic colloids(gelatins and 4%albumin).Based on current knowledge,we recommend that hyperoncotic solutions(dextrans,hydroxyethylstarches,or 20-25%albumin
18、)not be used for routine fluid resuscitation because they carry a risk for renal dysfunction.Brochard L et al.Am J Respir Crit Care Med.2010;181(10):1128-55.50 2022-12-4 Decreased glomerular filtration pressure due to increased intracapillary oncotic pressure and(direct)colloid nephrotoxicity(osmoti
19、c nephrosis)are the two purported mechanisms responsible for the higher incidence of renal dysfunction with hyperoncotic colloids than with crystalloids or hypooncotic colloids.Brochard L et al.Am J Respir Crit Care Med.2010;181(10):1128-55.51 2022-12-4 In addition,many adverse effects have been des
20、cribed using synthetic colloids.These include anaphylactic and anaphylactoid reactions,blood coagulation disorders,and,in the case of starches,also liver failure and pruritus.Brochard L et al.Am J Respir Crit Care Med.2010;181(10):1128-55.52 2022-12-4补多少？&补多快？53 Resuscitation goals:(1C)CVP 8-12 mmHg
21、(A higher target CVP of 12-15 mmHg is recommended in the presence of mechanical ventilation or pre-existing decreased ventricular compliance.)MAP65 mm Hg Urine output 0.5 mL.kg-1.hr-1 Central venous(superior vena cava)oxygen saturation 70%,or mixed venous 65%R.Phillip Dellinger et al.Crit Care Med.2
22、008;36(1):296-327.54 2022-12-4CVP 8-12mmHg?55 Frank-Starling Curve56 2022-12-4心室P-V曲线57 2022-12-4Marik PE et al.Ann Intensive Care.2011;1(1):1.58 2022-12-4Marik PE et al.Ann Intensive Care.2011;1(1):1.59 2022-12-4Does Central Venous Pressure PredictFluid Responsiveness?60 Marik PE et al.Chest.2008;1
23、34(1):172-8.61 2022-12-4 Conclusions:This systematic review demonstrated a very poor relationship between CVP and blood volume as well as the inability of CVP/CVP to predict the hemodynamic response to a fluid challenge.CVP should not be used to make clinical decisions regarding fluid management.Mar
24、ik PE et al.Chest.2008;134(1):172-8.62 2022-12-4Discussion In other words,our results suggest that at any CVP the likelihood that CVP can accurately predict fluid responsiveness is only 56%(no better than flipping a coin).Furthermore,an AUC of 0.56 suggests that there is no clear cutoff point that h
25、elps the physician to determine if the patient is“wet”or“dry”.Marik PE et al.Chest.2008;134(1):172-8.63 2022-12-4Discussion It is important to emphasize that a patient is equally likely to be fluid responsive with a low or a high CVP.The results from this study therefore confirm that neither a high
26、CVP,a normal CVP,a low CVP,nor the response of the CVP to fluid loading should be used in the fluid management strategy of any patient.Marik PE et al.Chest.2008;134(1):172-8.64 2022-12-4Discussion It should also be recognized that CVP was a component of early goal-directed therapy in the landmark ar
27、ticle by Rivers and colleagues.However,both the control and intervention groups had CVP targeted to 8 to 12mm Hg.Marik PE et al.Chest.2008;134(1):172-8.65 2022-12-4Discussion Based largely on the results of the early goal-directed therapy study,the Surviving Sepsis Campaign guidelines for management
28、 of severe sepsis and septic shock recommend a CVP of 8 to 12mmHg as the“goal of the initial resuscitation of sepsis-induced hypoperfusion”and“a higher targeted central venous pressure of 1215 mmHg”in patients receiving mechanical ventilation.Marik PE et al.Chest.2008;134(1):172-8.66 2022-12-4Discus
29、sion The results of our study suggest that these recommendations should be revisited.Marik PE et al.Chest.2008;134(1):172-8.67 2022-12-4MAP65 mmHg?68 Emanuel Rivers et al.N Engl J Med 2001;345:1368-7769 2022-12-4MAPmmHgMAPmmHgMAPmmHg tonometry PCO2 gapred cell velocitycapillaryflowurineoutput1501005
30、013%*NE dosecardiac indexSVR15010050200%lactate3.14.7998*LeDoux D et al.Crit Care Med.2000;28(8):2729-32.70 2022-12-4Mean arterial pressureOrganBloodflowmmHg6571 2022-12-4Mean arterial pressureOrganBloodflowmmHg65Strandgaard S et al.Br Med J.1973;1(5852):507-1072 2022-12-4Urine output 0.5 mL.kg-1.hr
31、-1?73 ScvO2 70%?74 Variable and Treatment groupBase Line0 hrCVP mmHgStandard therapy 6 8EGDT5 9MAP mmHgStandard therapy 24EGDT74 276 hrs after the start of therapyTotal fluids(mL)Any vasopressor(%)12 714 43499 24384981 2984 18951966 1677 1027.4ScvO2%Standard therapy 49 13EGDT 49 11Emanuel Rivers et
32、al.N Engl J Med 2001;345:1368-7775 Crit Care Med 2006,34:1025-1032Initial ScvO2 72 11%Initial ScvO2 73 13%Initial ScvO2 74 10%Initial ScvO2 73 11%76 2022-12-4其他指标?Lactate clearance Passive leg raising PPV Dynamic measures of echocardiographic function 77 2022-12-4Lactate clearance?78 the researchers
33、 suggest that in the initial resuscitation phase of severe sepsis and septic shock,patients with elevated lactate levelsa marker of tissue hypoperfusionshould be normalized as quickly as possible in facilities that do not have the capability to target central venous oxygen saturation(weak recommenda
34、tion;Grade 2C).Surviving Sepsis Campaign Previews Updated Guidelines for 201279 2022-12-4Passive leg raising?80 Marik PE et al.Ann Intensive Care.2011;1(1):1.81 2022-12-4Marik PE et al.Ann Intensive Care.2011;1(1):1.82 2022-12-4Prau S et al.Crit Care Med.2010;38(3):819-25.83 2022-12-4 Conclusions:Ch
35、anges in stroke volume,radial pulse pressure,and peak velocity of femoral artery flow induced by passive leg raising are accurate and interchangeable indices for predicting fluid responsiveness in nonintubated patients with severe sepsis or acute pancreatitis.Prau S et al.Crit Care Med.2010;38(3):81
36、9-25.84 2022-12-4Study name sample size AUC Monnet CCM 2006 71 0.96Lafanchre CC 2006 22 0.95Lamia ICM 2007 24 0.96Maizel ICM 2007 34 0.89Monnet CCM 2009 34 0.94Thiel CC 2009 102 0.89Biais CC 2009 30 0.96Preau CCM 2010 34 0.94 0.95PLR-induced changes in CO Cavallaro F et al.Intensive Care Med.2010;36
37、(9):1475-83.85 2022-12-4 Conclusions:Passive leg raising-induced changes in cardiac output can reliably predict fluid responsiveness regardless of ventilation mode and cardiac rhythm.PLR-cCO has a significantly higher predictive value than PLR-cPP.Cavallaro F et al.Intensive Care Med.2010;36(9):1475
38、-83.86 2022-12-4PPV?87 ABVentricular preloadStroke volume88 2022-12-4SensitivityPPVCVPPAOP1-SpecificityMichard F et al.Am J Respir Crit Care Med.2000;162(1):134-889 2022-12-4Additions to Fluid Therapy Recommendations（2012）The committee also recommends that a fluid challenge technique using increment
39、al fluid boluses be continued for as long as patients improve hemodynamically based on dynamic(eg,delta pulse pressure)or static(eg,arterial pressure)variables(strong recommendation;Grade 1C).90 2022-12-4Dynamic measures of echocardiographic function?91 Levitov A et al.Cardiol Res Pract.2012;2012:819696.92 2022-12-4Singer P et al.Isr Med Assoc J.2011;13(11):692-3.93 2022-12-4谢谢94 2022-12-4
