Sepsis患者的液体管理p 患者，男，39岁 。p主诉：右下腹痛伴发热3天,加重1天。p8月14日入急诊室，8月15日1405入院。Case p腹痛待查p局限性腹膜炎p急性阑尾炎 入普外科时诊断p感染性休克p急性坏疽性阑尾炎p阑尾周围脓肿 p阑尾切除术后pARDSp I型呼吸衰竭入ICU诊断p8.15 术中进量 1000ml, 出血 20mlpDATE IN OUT Balance Tmax p8.16 4450 1800 +2650 36.8p8.17 1610 4490 -1880 37.3p8.18 1250 2450 -1200 37.5p8.19 1860 2740 -880 37.3Fluid BalanceARDS(急性呼吸窘迫综合征)静脉输液的历史The discovery of the circulation of the blood by William Harvey in 1628 formed the basis for the rationale for IV injections and infusions输液目的普通静脉输液（按要求稀释药物）容量复苏Volume resuscitation(液体复苏 Fluid resuscitation)（补充患者体内不足）Fluid is a drug that can be overdosed in the ICUS.L Goldstein Department of Nephrology and HypertensionCincinnati Childrens Hospital Medical Center, USA如何实施液体管理？没有明确答案在中国In the ICU:重症患者In the wards:前重症患者or重症患者Patients with SIRS毛细血管渗漏综合征（Capillary Leak Syndrome，CLS） l定义l毛细血管内皮细胞损伤，血管通透性增高，造成间质水肿（如肺泡水肿，气体交换受限），组织缺氧又加重毛细血管内皮细胞损伤，形成恶性循环，引起器官功能障碍l病因l严重创伤、Sepsis、ARDS、烧伤、体外循环手术、再灌注损伤等。l主要表现l一般：全身水肿，血液浓缩，低蛋白血症l器官：肺，肝，脑各种情况下的水的分布内毒素血症-高容量组高容量复苏与死亡率：高容量复苏与死亡率：动物实验动物实验内毒素血症-中等容量组腹膜炎-高容量组腹膜炎-中等容量组结论结论 高容量复苏增加脓毒症的死亡率。液体管理策略影响脓毒症的预后。生存率大量研究表明：大量研究表明：液体过多与预后不佳有关液体过多与预后不佳有关1. Simmons RS, Berdine GG, Seidenfeld JJ, et al: Fluid balance and the adult respiratory distress syndrome. Am Rev Respir Dis 1987;135:9249292. Humphrey H, Hall J, Sznajder I, et al: Improved survival in ARDS patients associated with a reduction in pulmonary capillary wedge pressure. Chest 1990; 97:117611803. Schuller D, Mitchell JP, Calandrino FS, et al: Fluid balance during pulmonary edema. Is fluid gain a marker or a cause of poor outcome? Chest 1991; 100:106810754.Alsous F, Khamiees M, DeGirolamo A, et al: Negative fluid balance predicts survival in patients with septic shock: A retrospective pilot study. Chest 2000; 117:17491754大量研究表明：大量研究表明：液体过多与预后不佳有关液体过多与预后不佳有关5. Rivers E, Nguyen B, Havstad S, et al : Early Goal-Directed Therapy Collaborative Group: Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001; 345:136813776. Sakr Y, Vincent JL, Reinhart K, et al; Sepsis Occurence in Acutely Ill Patients Investigators: High tidal volume and positive fluid balance are associated with worse outcome in acute lung injury. Chest 2005; 128:309831087. Vincent JL, Sakr Y, Sprung CL, et al: Sepsis Occurrence in Acutely Ill Patients Investigators: Sepsis in European intensive care units: Results of the SOAP study. Crit Care Med 2006; 34:3443538. Rosenberg AL, Dechert RE, Park PK, et al: NIH NHLBI ARDS Network: Review of a large clinical series: Association of cumulative fluid balance on outcome in acute lung injury: A retrospective review of the ARDSnet tidal volume study cohort. J Intensive Care Med 2009; 24:3546大量研究表明：大量研究表明：液体过多与预后不佳有关液体过多与预后不佳有关9. Rosenberg AL, Dechert RE, Park PK, et al; NIH NHLBI ARDS Network: Review of a large clinical series: Association of cumulative fluid balance on outcome in acute lung injury: A retrospective review of the ARDSnet tidal volume study cohort. J Intensive Care Med 2009; 24:354610. Stewart RM, Park PK, Hunt JP, et al; National Institutes of Health/National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome Clinical Trials Network: Less is more: Improved outcomes in surgical patients with conservative fluid administration and central venous catheter monitoring. J Am Coll Surg 2009; 208:72573511. Boyd JH, Forbes J, Nakada TA, et al: Fluid resuscitation in septic shock: A positive fluid balance and elevated central venous pressure are associated with increased mortality. Crit Care Med 2011; 39:25926512. The RENAL Replacement Therapy Study Investigators: An observational study of fluid balance and patient outcomes in the randomized evaluation of normal vs. augmented level of replacement therapy trial. Crit Care Med 2012; 40:17531760静态评估动态评估两种序贯容量管理策略两种序贯容量管理策略Adequate initial fluid resuscitation (AIFR)早期恰当容量复苏早期恰当容量复苏 administration of an initial fluid bolus of 20 mL/kg prior to to vasopressor therapy initiation and achievement of a central venous pressure of 8 mm Hg within 6 h after the onset of therapy with vasopressorsConservative late fluid management (CLFM)后期限制性液体管理后期限制性液体管理 even-to-negative fluid balance measured on at least 2 consecutive days during the first 7 days after septic shock onset何谓何谓“限制性容量管理限制性容量管理”（conservative or restricted fluid management）维持每日液体进出量基本或维持每日液体进出量基本或(尽可能尽可能)负平负平衡衡 Daily even-to-negative fluid balance 满足细胞、组织适当的灌注满足细胞、组织适当的灌注为细胞、组织提供足够的氧气、足够的营养为细胞、组织提供足够的氧气、足够的营养维持重要器官功能维持重要器官功能Fluid may be a friend when appropriately titratedduring the resuscitation, or ebb, phase ofacute lung injury. However, excess fluid becomesan enemy when it is no longer physiologicallyneeded.Emanuel P. Rivers, M.D., M.P.H.Fluid-Management Strategies in Acute Lung Injury Liberal, Conservative, or Both? N Engl J Med 354;24 2598 june 15, 2006