1、胶体液胶体液白蛋白白蛋白和血浆和血浆 右旋糖苷右旋糖苷羟乙基淀粉羟乙基淀粉明胶明胶晶体液晶体液林格氏液林格氏液生理盐水生理盐水晶体液晶体液 VS 胶体液胶体液a VS 胶体液胶体液 胶体液胶体液b 1.1.提供每日基础液体需要量提供每日基础液体需要量2.补充组织间质和细胞内液丧失量补充组织间质和细胞内液丧失量 3.补充尿液丧失的液体量补充尿液丧失的液体量晶Crystalloids1.维持正常血容量和血流动力学稳定维持正常血容量和血流动力学稳定 2.改善微循环改善微循环 3.维持足够的血浆胶体渗透压维持足够的血浆胶体渗透压 4.保证组织细胞氧的运输保证组织细胞氧的运输5.防止自由基导致的细胞再灌
2、注损伤防止自由基导致的细胞再灌注损伤 6.防止、延缓创伤导致的血液高凝状态防止、延缓创伤导致的血液高凝状态胶Colloidsuntil hematocrit30%以后每个10kg 1Diaspirin Cross-Linked Hemoglobin is Efficacious in Gut Resuscitation As measured by GI Tract Optode，Frankel HL,J Trauma,1996正常组织正常组织乳酸林格溶液组乳酸林格溶液组组织组织水肿水肿-80-60-40-20020406080100120140Changes in tissue pO2 in
3、 patients undergoing abdominal surgeryScanning EM:1 minute after substance P(inflammation)IL-6(pg/dl)0100200300400500*+200250300350400450500+*1st POD5 hrs ICUend of surgerybaseline 5%HA HES 130/0.4255075100125150+*)50100150200250300350400450+*)术前丧失液体生理需要液体麻醉导致的血管扩张术中失血总量是麻醉科医生输液的准则，但合理吗？第三间隙丢失湿wet1l
4、i SZ,Kurz A,et al:Effect of supplemental pre-operative fluid on postoperative nausea and vomiting.Anaesthesia,2003,58,775803Gan TJ,et al:Goal-directed Intraoperative Fluid Administration Reduces Length of Hospital Stay after Major Surgery.Anesthesiology 2002;97:8206Holte K,et al.Liberal Versus Restr
5、ictive Fluid Administration to Improve Recovery After Laparoscopic Cholecystectomy,A Randomized,Double-Blind Study.Annals of Surgery,2004;240(5):892-899湿wet干dryKita T,et al.Fluid management and postoperative respiratory disturbances in patients with transthoracic esophagectomy for carcinoma.J Clin A
6、nesth,2002,14:252-256.Lobo DN,et al.Effect of salt and water balance on recovery of gastrointestinal function after elective colonic resection:a randomised controlled trial.Lancet 2002;359:181218体重静脉补液量入液总量尿钠排出量两组并发症和两组并发症和30天死亡人数比较天死亡人数比较两组固体和液体食物两组固体和液体食物排空时间比较排空时间比较Brandstrup B,Pott F,et al:Effec
7、ts of Intravenous Fluid Restriction on Postoperative Complications:Comparison of Two Perioperative Fluid Regimens.A Randomized Assessor-Blinded Multicenter Trial.Annals of Surgery,2003,238,641 648.升补充液体经口补充液体静脉补充 0.9%的盐水静脉补充 5%葡萄糖静脉补充 HAES 6%静脉补充其他或非特异性液体术后期Day 1Day 2Day 3Day 4Day 5Day 67,06,05,04,0
8、3,02,01,00R SR SR SR SR SR SR S*R=限量组S=标准组生理盐水生理盐水公斤体重变化情况术后Day 1Day 2Day 3Day 4Day 5Day 67,06,05,04,03,02,01,00R SR SR SR SR SR SR S*R=限量组S=标准组静脉补液和体重增加的相关并发症n=51n=48n=42n=40n=52n=43并发症发生率10090807060504030201005.5 L2.5 kgn=40n=52n=43输入液体量增加体重干dry干dry湿wetVS.Holte K.TATM 2004,6:5455Kudsk KA.Evidence
9、for Conservative Fluid Administration Following Elective Surgery.Annals of Surgery,2003,238,649 650.曲线：假设的危险程度曲线；直线：临床研究中“开放”补液和“限制”补液的分界；直线：临床研究中适宜补液与不适宜补液的分界 开放Central venous and禁食10h累计缺失1100mlProtocol for Early Goal-Directed Therapy Rivers E,et al.N Engl J Med,2001Hospital admissionSupplemental o
10、xygenendotracheal intubation and mechanical ventilationCentral venous and arterial catheterizationCVPMAPScvO2GoalachievedSedation,paralysis(if intubated),or bothCrystalloidColloidVasoactive agentsTransfusion of red cells until hematocrit30%Intropic agents8-12 mmHg8 mmHg90 mmHg65 and 90 mmHg70%70%70%
11、70%YesNoProtocol for Early Goal-Directed Therapy Rivers E,et al.N Engl J Med,2001脓毒症：HCT 30%吸氧、动脉和中心静脉置管气管插管+通气镇痛、镇静、肌松扩容利尿血管活性药：去甲肾上腺素或硝酸甘油Heart Rate and Blood Pressure during Blood Loss210120180150906030Base020406080100120140160Heart rateSys BPTime(minutes)Controlled HemorrhageRe-transfusion800ml8
12、00 mlHamilton-Davies et al Intensive Care Med 23:276-281,19977.007.057.107.157.207.257.307.357.407.457.50Time(minutes)Gastric pHiControled hemorrhageRe-transfusion800 ml800 ml210120180150906030BaseGUT during Blood LossHamilton-Davies et al Intensive Care Med 23:276-281,1997小动脉阻力小动脉阻力心心 率率心排血量心排血量心肌收
13、缩力心肌收缩力血管容量血管容量后负荷后负荷主动脉阻抗主动脉阻抗前负荷前负荷静脉回流静脉回流静脉张力静脉张力同步同步 80 20静脉补液和体重增加的相关并发症术后根据体重计算补液量Q(L/min)静脉回流正常血容量不足,静脉回流增加累计缺失量累计缺失量生理需要量生理需要量麻醉后血管扩张麻醉后血管扩张失血量失血量第三间隙缺失量第三间隙缺失量Thank you for your attention胶体液胶体液白蛋白白蛋白和血浆和血浆 右旋糖苷右旋糖苷羟乙基淀粉羟乙基淀粉明胶明胶晶体液晶体液林格氏液林格氏液生理盐水生理盐水Scanning EM:1 minute after substance P(inflammation)IL-6(pg/dl)0100200300400500*+
