围术期液体治疗进展

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,围术期液体治疗进展,病例介绍：病史,患者男性，,53,岁，体重,86kg,，身高,172cm,现病史,左前额骨纤维瘤切除术后,24,年,术后复发,15,年伴左眼视力下降进行性加重,入院诊断：左额眶沟通瘤,瘤切除术,既往史,无高血压、心脏病、糖尿病等病史,磺胺药过敏,病例介绍：麻醉、手术过程,(6,月,22,日,),入室,BP 140/80mmHg,，,HR 70 bpm,，,S,P,O,2,97%,桡动脉压、中心静脉压、,3,个外周静脉通路,8:30,麻醉诱导,9:40,手术开始,14:30,完成左颞部、颅眶内肿瘤切除,15:00,开始颅底肿瘤切除。,23:10,手术结束，回,SICU,病例介绍：术中液体平衡,入量,出量,胶体液,佳乐施,4500,出血,18000,万汶,5500,尿量,3800,血浆,2000,血小板,400,血液,自体回收血,6600,库血,3800,晶体液,LR,6500,NS,1800,总入量,32200,总出量,21800,术中液体平衡：,+10400mL,入,ICU,23,：,20,23,日,8Am,24,日,8Am,25,日,8Am,26,日,8Am,27,日,8Am,28,日,8Am,29,日,8Am,入量,人工胶体,10000,自体回收血,6600,血制品,血浆,2000,600,200,血小板,400,200,白蛋白,100,200,200,红细胞,3800,400,晶体液,8300,694,2452,1873,2920,1601,1341,1163,鼻饲,440,940,1220,1630,出量,出血,18000,尿,3800,520,4940,4580,3950,4050,4150,4200,引流,250,550,100,100,50,总入量,32200,794,3952,2573,2910,2541,3161,3167,总出量,21800,770,5490,4680,4050,4100,4150,4200,出入量差值,+10400,+24,-1538,-2107,-1140,-1558,-989,-2357,病例介绍：术后液体平衡情况,术后第,17,天液体总平衡,9665,mL,病例介绍：术后胸部,X,线片变化,6.23(,术后第,1,日,),6.28(,术后第,6,日,),6.26(,术后第,4,日,),病例介绍：术后一般生命体征变化,项目,入,ICU,23:20,23,日,8Am,24,日,8Am,25,日,8Am,26,日,8Am,27,日,8Am,28,日,8Am,29,日,8Am,30,日,8Am,T,C,38,37.8,36,36.9,36.8,36.4,38.5,37,HR,89,72,98,81,78,79,69,89,64,BP,134/77,104/60,115/71,109/64,123/69,141/75,122/63,114/66,119/67,CVP,13,12,11,10,11,7,10,SpO2,100,96,98,94,98,97,97,100,100,R,13,10,12,17,17,15,14,14,14,病例介绍：术后动脉血气变化,项目,入,ICU,23:20,23,日,8Am,24,日,8Am,25,日,8Am,26,日,8Am,27,日,8Am,28,日,8Am,29,日,8Am,30,日,8Am,Mode,Bilevel,CPAP,Spont,FiO,2,100,40,60,70,45,50,50,40,30,PEEP,5,5,8,10,10,8,8,5,0,pH,7.29,7.36,7.51,7.49,7.43,7.48,7.51,7.44,7.39,PaCO,2,37.4,42.4,29.6,33.4,38.6,42.9,42.6,37.0,39.4,PaO,2,189.4,74.5,124.6,85.6,95.0,82.3,87.4,101.1,82.3,BE,-8.1,-2.2,1.2,2.4,3,7.1,9.4,0.8,-1.4,PaO,2,/,FiO,2,189.4,186.2,207.7,122.3,211.1,166.4,218.5,252.7,274.3,病例介绍：,术后情况,术后第,1,天,(6,月,23,日,),：神志恢复，全身水肿,甘露醇,125mL q8h,、速尿,20mg q8h,，交替,术后第,3,天,(6,月,25,日,),：,肌酐,升高停甘露醇,术后第,5,天,(6,月,27,日,),：气管切开,术后第,7,天,(6,月,29,日,),：脱离呼吸机,术后第,8,天,(6,月,30,日,),：回病房,术后,2,月,(8,月,25,日,),：出院,液体治疗的传统观念,液体治疗过度的危害,限制性液体,“目标引导”的液体治疗,外科应激的内分泌反应,Moore FD. Metabolic care of the surgical patient. Philadelphia: WB Saunders, 1959.,外科应激,水钠潴留,围术期应限制液体入量,?,大手术,细胞外液再分布,(“,第三间隙”,),细胞外液容量,应给予晶体液补充第三间隙的液体丢失,?,Shires T, Ann Surg 1961;154:80310,“,第三间隙,”,的细胞外液丢失,术中液体治疗计算法,术前液体缺失量,生理维持需要量,第三间隙丢失量,失血量,接受胃切除术病人,(70kg),的术中液体治疗,时间,补偿输液量,缺失量,维持量,失血,第三间隙,本小时输液量,累计输液量,诱导前,350,220,110,0,0,680,680,切皮前,220,110,0,0,330,1010,第一小时,220,110,300,350,980,1990,第二小时,220,110,300,350,980,2970,第三小时,220,110,150,350,830,3800,第四小时,-,110,0,200,330,4130,术前,Hb 15g/dL,禁食,10hs,维持输液速度,110mL/h,Miller RD, ed. Anesthesia, 5th ed. 2000:1606 7.,围术期液体治疗,大的主动脉或腹部手术：除补充失血外术中输液,4-6L,周围血管手术：失血量很少，但手术当天,24h,的输液量超过,6 L,腹腔镜胆囊切除术：手术当天,24h,的输液量将近,4L,Lang K, Anesth Analg 2001; 93: 405-9,Christopherson R, Anesthesiology 1993; 79: 422-34,Glaser F, Ann Surg 1995; 221: 372-80,围术期液体治疗,大手术后病人体重增加,5-10 kg,并不罕见,术后体重增加主要因围术期液体正平衡所致,Holte K, Br J Anaesth 2002;89: 62232.,Kudsk KA. Ann Surg 2003;238:649 50.,液体治疗的传统观念,液体治疗过度的危害,限制性液体,“目标引导”的液体治疗,How much harm does excess fluid really cause?,SICU,中液体过负荷的发生率和危害,前瞻性研究,48,例连续病人体重的急性变化及其对临床治疗的预后的影响,Crit Care Med. 1990 Jul;18(7):728-33.,Postoperative fluid overload: not a benign problem.,Lowell JA, Schifferdecker C, Driscoll DF, Benotti PN, Bistrian BR.,Nutrition Support Service, New England Deaconess Hospital, Harvard Medical School, Boston, MA 02215.,40%,的病人存在输液过量,(,体重增加,术前,10%),输液过量病人,并发症发生率更高,ICU,停留时间更长,输液过量病人的死亡率更高,(31.6% vs. 10.3%),Crit Care Med. 1990 Jul;18(7):728-33.,Perioperative weight gain and mortality,体重增加越多，死亡率越高,Crit Care Med. 1990 Jul;18(7):728-33.,*,P,13,例既往健康病人、,ASA I (10/13),、平均,38,岁，术后,38h,内死于肺水肿,无明确的先兆症状,心跳骤停是最常见,(n=8),第一个,24h,液体平衡平均,+7L,CHEST 1999; 115:13711377,肺切除手术后并发症和住院期间死亡的危险因素,107,例择期肺切除术病人,术后并发症发生率,29%,，总死亡率,10.3%,术后并发症和死亡分析的参数,术后并发症的危险因素,(logistic,回归分析,),术后死亡的危险因素,(logistic,回归分析,),前瞻性、双盲、随机交叉试验,12,例健康志愿者在,3h,内接受,LR,输注,大量输注,(40mL/kg),背景输注,(5mL/kg),(Anesth Analg 2003;96:1504 9),大量输注,LR,导致肺功能明显下降，并持续,24h,(Anesth Analg 2003;96:1504 9),Why are patients sensitive to large volumes of crystalloid?,麻醉、手术期间晶体液的清除速度是健康志愿者的,10-20%,静脉输入的晶体液在,20-30min,后即离开血管腔，与组织间隙液体平衡,Hahn RG. Anesth Analg 2007; 105: 304,液体治疗对心肌做功,Starling,曲线的影响,液体治疗对肺部跨毛细血管膜液体流动的影响,毛细血管内静水压,毛细血管内胶体渗透压,组织内静水压,组织内胶体渗透压,Aggressive fluid strategies adversely affect,every system and organ,Prowle JR et al. Nat Rev Nephrol 2010;6:107,液体治疗的传统观念,液体治疗过度的危害,限制性液体治疗,“目标引导”的液体治疗,术中液体治疗是否影响术后呼吸功能恢复,112,例因食道癌接受经胸食道切除手术的病人,回顾性研究：非限制性输液,vs.,限制性输液,(,液体平衡,= 1-2mL/kg/h, CVP5 mmHg),Journal of Clinical Anesthesia 14:252256, 2002,围术期指标,Journal of Clinical Anesthesia 14:252256, 2002,术后气管切开的危险因素,Journal of Clinical Anesthesia 14:252256, 2002,术后支气管镜吸痰的危险因素,Journal of Clinical Anesthesia 14:252256, 2002,术中限制性液体治疗可改善术后呼吸功能恢复,Journal of Clinical Anesthesia 14:252256, 2002,术中限制性输液对结直肠切除手术后并发症发生情况的影响,172,例病人，随机、观察者单盲、多中心研究,限制性输液组,(,维持术前体重,),标准围术期输液组,(,Ann Surg,2003;238: 641648),术中液体治疗,(,Ann Surg,2003;238: 641648),围术期输液量及体重变化,(,Ann Surg,2003;238: 641648),术后并发症发生情况比较,(,Ann Surg,2003;238: 641648),术后并发症与术日输液量和体重增加量的关系,(,Ann Surg,2003;238: 641648),P80mmHg, UO0.5mL/kg/h),治疗组：标准治疗,+,维持,O,2,ER27%,CHEST 2007; 132:18171824,.,O,2,ERe,=,(Sa,O,2,-,Scv,O,2,/Sa,O,2,),Therapeutic interventions,Total,Intraop,Postop,CHEST 2007; 132:18171824,.,Number and type of organ failures,住院时间：,死亡率：,2.9% vs 3.0%,CHEST 2007; 132:18171824,.,早期治疗维持,O2ER500mL,对照组：标准液体治疗,治疗组：经食道超声多普勒,维持最佳,SV,Anesthesiology 2002; 97:8206,Intraoperative fluid managementalgorithm,Anesthesiology 2002; 97:8206,Incidence of Postoperative Complications,Anesthesiology 2002; 97:8206,术后进食固体食物时间：,对照组,0.5),天,vs,治疗组,(3,0.5),天,(P=0.01),术后住院时间：,对照组,(7,3),天,vs,治疗组,(5,3),天,(P=0.03),Anesthesiology 2002; 97:8206,目标引导液体治疗,促进胃肠功能恢复,减少,PONV,发生,缩短住院时间,术中经食道超声多普勒引导的液体治疗改善预后,?,RCT,研究, 128,例拟行结直肠手术病人,对照组：常规循环监护，,CVP 12-15mmHg,治疗组：常规循环监护，,SV,监护,维持最佳,SV,Br J Anaesth 2005; 95: 63442,Br J Anaesth 2005; 95: 63442,Postoperative hospitalization and recovery of gut funtion,Br J Anaesth 2005; 95: 63442,Postoperative complication,Br J Anaesth 2005; 95: 63442,术中多普勒超声引导的液体治疗,改善胃肠道功能恢复,减少胃肠道并发症发生,缩短住院时间,Br J Anaesth 2005; 95: 63442,5,项,RCT,研究，,420,例腹部大手术病人,食道多普勒目标引导治疗,常规治疗,目标引导的围术期液体治疗改善病人预后,?,Anaesthesia, 2008, 63, pages 4451,ICU admissions,Anaesthesia, 2008, 63, pages 4451,目标引导治疗减少需入,ICU,病人数量,Return,of bowel function,Anaesthesia, 2008, 63, pages 4451,目标引导治疗加速术后胃肠道功能恢复,Overall rate of complications,Anaesthesia, 2008, 63, pages 4451,目标引导治疗减少术后并发症发生率,Hospital,stay,Anaesthesia, 2008, 63, pages 4451,目标引导治疗缩短术后住院时间,Phan TD et al. J Am Coll Surg 2008; 207: 935,Decreased length of stay with GDT,Phan TD et al. J Am Coll Surg 2008; 207: 935,Decreased time to resume full diet with GDT,Phan TD et al. J Am Coll Surg 2008; 207: 935,Decreased morbidity with GDT,Phan TD et al. J Am Coll Surg 2008; 207: 935,Average increased volume colloid 700 mL,Phan TD et al. J Am Coll Surg 2008; 207: 935,亚临床的血容量不足可导致肠道功能障碍,目标引导的围术期液体治疗可减少血容量不足，预防肠道功能障碍发生,Phan TD et al. J Am Coll Surg 2008; 207: 935,小 结,输液过多或过少均对病人预后不利,目标是维持最佳血容量，避免过负荷,/,容量不足,应根据血流动力监测结果进行目标引导的个体化治疗，而不应对所有病人采用同样的治疗方法,谢谢观赏！,2020/11/5,90,