液體復(fù)蘇膠體的地位課件

液體復(fù)蘇------膠體的地位中山大學(xué)附屬第一醫(yī)院重癥醫(yī)學(xué)科管向東液體復(fù)蘇------膠體的地位中山大學(xué)附屬第一醫(yī)院---170多年前（1832年），一位蘇格蘭醫(yī)師，發(fā)現(xiàn)了這種通過靜脈血管把藥液送入人體的治療手段……---170多年前（1832年），明膠GELATIN白蛋白ALBUMIN1915WorldWarI1945WorldWarII1960’WarInVietnam右旋糖苷DEXTRAN羥乙基淀粉1943WorldWarII為什么要開發(fā)出這些膠體?明膠白蛋白191519451960’右旋糖苷羥乙基淀粉194重癥液體復(fù)蘇的重要性膠體及其作用目前的爭論總結(jié)重癥液體復(fù)蘇的重要性什么是膠體?膠體（colloid）又稱膠狀分散體（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€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）什么是膠體?膠體（colloid）又稱膠狀分散體（collo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%)人體白蛋白的含量與分布細(xì)胞細(xì)胞外液體液40%組織間液血漿5%2022/12/16Frank-Starling定律2022/12/12Frank-Starling定律(Multi-)OrganFailureCelldystructionbyimbalancebetweenO2-supplyandO2-consumptionO2undersupportO2debtMacrocirculatorydysfunction

COMicrocirculatorydysfunction(Multi-)OrganFailureCelldysWhatelsebesidesvolumerestrictionandexpansion?FluidresuscitationTissueoxygenationCapillaryleakameliorationHemodynamicsClinicaloutocmeRiskofAnaphylaxisEffectoncoagulationEffectonRenalfunctionJean-LouisVincent,MaxHarryWeil,CritCareMed2006;34:1333–1337WhatelsebesidesvolumerestrIntroductionAcutelyillpatientsfrequentlyrequirefluidrepletion.HypovolemiaExternalloss:bleeding,gastrointestinal,urinarytracts,skinInternalloss:extravasationofblood,exudation/transudationoffluidsRelativeHypovolemia:increasesvenouscapacitanceSepsis,drugsVolumerepletionmaybeessentialtorestorecriticallevelsofcardiacoutputandarterialpressure,resultinginmorenormalperfusionofvitalorgansandtissues.Jean-LouisVincent,MaxHarryWeil,CritCareMed2006;34:1333–1337IntroductionAcutelyillpatienAcutelyillpatientsfrequentlyrequirefluidrepletionHypovolemia:externalloss&internallossRelativeHypovolemia:increasesvenouscapacitanceVolumerepletionmaybeessentialRestorecriticallevelsofcardiacoutputandarterialpressureMorenormalperfusionofvitalorgansandtissuesJean-LouisVincent,MaxHarryWeil,CritCareMed2006;34:1333–1337AcutelyillpatientsfrequentlIntroductionHemorrhage:Benefit/riskoffluidrepletionmustbeassessedBenefitsofdelayedresuscitationLargevolumeoffluidredcelldeficitoxygendeficitPersistenthypovolemiawillresultinMODSFluidrepletionistypicallymoreeffectiveduringhypovolemicstatesbutislesseffectiveinlaterstages.Jean-LouisVincent,MaxHarryWeil,CritCareMed2006;34:1333–1337IntroductionHemorrhage:Fluidr“fluidchallenge”Jean-LouisVincent,MaxHarryWeil,CritCareMed2006;34:1333–1337DistinguishedfromconventionalfluidadministrationUsuallytocriticalpatientswithcardiorespiratoryfailureThefluidchallengeisreservedforhemodynamicallyunstablepatientsandoffersthreemajoradvantages:Quantitationofthecardiovascularresponseduringvolumeinfusion.Promptcorrectionoffluiddeficits.Minimizingtheriskoffluidoverloadanditspotentiallyadverseeffects,especiallyonthelungs.“fluidchallenge”Jean-LouisVi重癥液體復(fù)蘇的重要性膠體及其作用目前的爭論總結(jié)重癥液體復(fù)蘇的重要性復(fù)蘇液體種類白蛋白血漿?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+低右復(fù)蘇液體種類白蛋白明膠膠體液晶體液林格氏液右旋糖苷羥乙基淀晶體液復(fù)蘇？贊成使用晶體液的理由：費用低，容易得到對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）擴容效率高反對使用晶體液的理由：平均留駐時間短（只有45min）液體輸入量大造成血清白蛋白的稀釋，血滲透壓降低，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.晶體液復(fù)蘇？贊成使用晶體液的理由：KoustovaE,STheedemaproblemofcrystalloidsiswellknown“Fluidispouredintotheinterstitialspaceonclinicalinformationgainedfromchangesinintravascularspace….…Theend

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

NHLBI終止高張鹽水治療休克的研究NIH所屬的國立心肺血液研究所(NHLBI)已經(jīng)終止了一項有關(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)試驗該試驗旨在研究高張鹽水溶液治療此類患者療效及安全性試驗終止的原因：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）相似

NHLBIHaltsStudyofConcentratedSalineforShockDuetoLackofSurvivalBenefit.AmericanAcademyofEmergencyMedicine

2009-16(3),

MedScapeToday

因生存率下降

NHLBI終止高張鹽水治療休克的研究NIH所液體復(fù)蘇膠體的地位課件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

單獨使用晶體無法維持膠體滲透壓→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COPbalanceessentialforbala

Artery

(Arteriole)動脈,小動脈Vein

(Venule)靜脈,小靜脈PlasmaProtein

ColloidOsmoticPressure膠體滲透壓22mmHg簡化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Artery(Arteriole)Vein(Venu膠體液的作用容量作用：維持血流動力學(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)運抗氧化作用……膠體液的作用容量作用：(colloid)151consecutively

majortraumapatientsWilliamC.Shoemaker

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

majWilliamC.Shoemaker

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

majortraumapatientsWilliamC.ShoemakerOutcomePNormalSubstanceP-1minlaterStudyofCapillaryLeakDirect:ScanningEM:normalendothelialcelljunctionDonaldMcDonald1999NormalSubstanceP-1minlaterCrit

CareMed2006;34:1775–1782CritCareMed2006;34:1775–17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硫醇含量GregoryJ.etc白蛋白增加血漿中抗氧化劑含量GregoryJ.etc.CritCareMed.2004;32:755-759

白蛋白增加血漿中抗氧化劑含量GregoryJ.etc.TheSAFEStudy

Alb:salinedeaths726:729(RR0.99)SimilarneworganfailuresICULOSHospitalLOSVentilatordurationRRTConclusion:OutcomewithalbumininICUnodifferentfromSalineQ:Doesthismeancrystalloidsandcolloidsarethesame?Doesthismeanallcolloidsaresame?Finferetal,NEJM2004;350:2247-56TheSAFEStudy

Alb:salinede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)重癥液體復(fù)蘇的重要性膠體液復(fù)蘇并無優(yōu)勢------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.膠體液復(fù)蘇并無優(yōu)勢------薈萃分析Objective: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.CochraneReport（2008）ObjectiveCochrane

Report（2008）Ascolloidsarenotassociatedwithanimprovementinsurvival,andastheyare

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

Cochrane的名字命名CochraneReport（2008）PerelP,膠體，ICU用，還是不用？膠體，ICU用，還是不用？FluidChallenge

500-100mlcristalloids300-500mlcolloidsover30mincontrolCVPorPAOPandreducespeed/volumeaccordingly

Grade1DSurvivingSepsisCampaign:Internationalguidelinesfor

managementofseveresepsisandsepticshock:2008CritCareMed2008Vol.36,No.1FluidChallenge500-100mlcriFigure.Differences(inpercentagefrombaseline)oftissueoxygentension(ptio2)inthetwovolumegroupsKatrinLang,JoachimBoldt,StefanSuttner,etal.

ColloidsVersusCrystalloidsandTissueOxygenTensioninPatientsUndergoingMajorAbdominalSurgery.AnesthAnalg2001;93:405–9Figure.Differences(inpercen白蛋白對于重癥患者結(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白蛋白對于重癥患者結(jié)論：白蛋白可以顯著降低重癥病例整體并發(fā)癥膠體：我們關(guān)心的組織氧代謝？SHOCK,2006

Vol.25,No.2,pp.103Y116膠體：我們關(guān)心的組織氧代謝？SHOCK,2006Vol SchortgenetcollLancet2001,357,911SurvivorsHEAorgelatineforSevereSepsis?SurvivorsHEAorgelatineforSResuscitation:selectionofFluidCrystalloidsorColloidscanbeusedFluidchallengeswithcolloidsallowformorerapidcompletionofchallenge.Crystalloid:Physiologic(0.9%)saltsolution(saline)MayincreaseserumchlorideconcentrationsBalancedsaltsolutions(Ringer’slactate/Hartmann’ssolution)Mildlyhypotonic,mayexacerbatecerebraledemaJean-LouisVincent,MaxHarryWeil,CritCareMed2006;34:1333–1337Resuscitation:selectionofFluResuscitation:selectionofFluidSAFEstudy:albuminvscrystalloidsolutionMortalityratewasidenticalHypoalbuminemiaisassociatedwithhighermorbidityVincentJLetal,AnnSurg2003;237:319–334:meta-analysisAlbuminadministrationmayreducecomplicationsincriticallyillpatientsSAFEtrial:Improvedsurvivalwithalbumininpatientswithsepsiswhoarehypoalbuminemia(relativeriskofdeath,0.87;95%CI,0.74–1.02;p0.06)AlbuminmaybebeneficialinthissubsetofcriticallyillpatientsJean-LouisVincent,MaxHarryWeil,CritCareMed2006;34:1333–1337Resuscitation:selectionofFlResuscitation:selectionofFluidSyntheticcolloidsolution:Hydroxyethylstarchsolutions:Lessexpensive,adverseeffectsonbloodclottingGelatins:SmallerMW,lesseffectiveplasmaexpanders,lowcostJean-LouisVincent,MaxHarryWeil,CritCareMed2006;34:1333–1337Resuscitation:selectionofFlResuscitation:selectionofFluidNointravenousfluidsolutionthatisidealinallclinicalsettingsNosecuredatasupportapreferenceforoneoveranotherThechoiceisbestmadecontingenton:theunderlyingdiseasethetypeoffluidthathasbeenlosttheseverityofcirculatoryfailuretheserumalbuminconcentrationofthepatienttheriskofbleeding.Jean-LouisVincent,MaxHarryWeil,CritCareMed2006;34:1333–1337Resuscitation:selectionofFl重癥液體復(fù)蘇的重要性膠體及其作用目前的爭論總結(jié)重癥液體復(fù)蘇的重要性總結(jié)重癥病人的液體復(fù)蘇，是最重要/最早的復(fù)蘇手段之一容量替代、血流動力學(xué)穩(wěn)定、組織氧合均是臨床液體復(fù)蘇的重要目標(biāo)液體選擇種類很多，無論何種液體（晶膠體），從使用開始，需要考慮不良作用膠體液的使用，要同時考慮容量以外問題目前，晶體或膠體復(fù)蘇孰優(yōu)孰劣，需要更有說服力的循證醫(yī)學(xué)證據(jù)支持總結(jié)重癥病人的液體復(fù)蘇，是最重要/最早的復(fù)蘇手段之一謝謝！謝謝！液體復(fù)蘇------膠體的地位中山大學(xué)附屬第一醫(yī)院重癥醫(yī)學(xué)科管向東液體復(fù)蘇------膠體的地位中山大學(xué)附屬第一醫(yī)院---170多年前（1832年），一位蘇格蘭醫(yī)師，發(fā)現(xiàn)了這種通過靜脈血管把藥液送入人體的治療手段……---170多年前（1832年），明膠GELATIN白蛋白ALBUMIN1915WorldWarI1945WorldWarII1960’WarInVietnam右旋糖苷DEXTRAN羥乙基淀粉1943WorldWarII為什么要開發(fā)出這些膠體?明膠白蛋白191519451960’右旋糖苷羥乙基淀粉194重癥液體復(fù)蘇的重要性膠體及其作用目前的爭論總結(jié)重癥液體復(fù)蘇的重要性什么是膠體?膠體（colloid）又稱膠狀分散體（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€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）什么是膠體?膠體（colloid）又稱膠狀分散體（collo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%)人體白蛋白的含量與分布細(xì)胞細(xì)胞外液體液40%組織間液血漿5%2022/12/16Frank-Starling定律2022/12/12Frank-Starling定律(Multi-)OrganFailureCelldystructionbyimbalancebetweenO2-supplyandO2-consumptionO2undersupportO2debtMacrocirculatorydysfunction

COMicrocirculatorydysfunction(Multi-)OrganFailureCelldysWhatelsebesidesvolumerestrictionandexpansion?FluidresuscitationTissueoxygenationCapillaryleakameliorationHemodynamicsClinicaloutocmeRiskofAnaphylaxisEffectoncoagulationEffectonRenalfunctionJean-LouisVincent,MaxHarryWeil,CritCareMed2006;34:1333–1337WhatelsebesidesvolumerestrIntroductionAcutelyillpatientsfrequentlyrequirefluidrepletion.HypovolemiaExternalloss:bleeding,gastrointestinal,urinarytracts,skinInternalloss:extravasationofblood,exudation/transudationoffluidsRelativeHypovolemia:increasesvenouscapacitanceSepsis,drugsVolumerepletionmaybeessentialtorestorecriticallevelsofcardiacoutputandarterialpressure,resultinginmorenormalperfusionofvitalorgansandtissues.Jean-LouisVincent,MaxHarryWeil,CritCareMed2006;34:1333–1337IntroductionAcutelyillpatienAcutelyillpatientsfrequentlyrequirefluidrepletionHypovolemia:externalloss&internallossRelativeHypovolemia:increasesvenouscapacitanceVolumerepletionmaybeessentialRestorecriticallevelsofcardiacoutputandarterialpressureMorenormalperfusionofvitalorgansandtissuesJean-LouisVincent,MaxHarryWeil,CritCareMed2006;34:1333–1337AcutelyillpatientsfrequentlIntroductionHemorrhage:Benefit/riskoffluidrepletionmustbeassessedBenefitsofdelayedresuscitationLargevolumeoffluidredcelldeficitoxygendeficitPersistenthypovolemiawillresultinMODSFluidrepletionistypicallymoreeffectiveduringhypovolemicstatesbutislesseffectiveinlaterstages.Jean-LouisVincent,MaxHarryWeil,CritCareMed2006;34:1333–1337IntroductionHemorrhage:Fluidr“fluidchallenge”Jean-LouisVincent,MaxHarryWeil,CritCareMed2006;34:1333–1337DistinguishedfromconventionalfluidadministrationUsuallytocriticalpatientswithcardiorespiratoryfailureThefluidchallengeisreservedforhemodynamicallyunstablepatientsandoffersthreemajoradvantages:Quantitationofthecardiovascularresponseduringvolumeinfusion.Promptcorrectionoffluiddeficits.Minimizingtheriskoffluidoverloadanditspotentiallyadverseeffects,especiallyonthelungs.“fluidchallenge”Jean-LouisVi重癥液體復(fù)蘇的重要性膠體及其作用目前的爭論總結(jié)重癥液體復(fù)蘇的重要性復(fù)蘇液體種類白蛋白血漿?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+低右復(fù)蘇液體種類白蛋白明膠膠體液晶體液林格氏液右旋糖苷羥乙基淀晶體液復(fù)蘇？贊成使用晶體液的理由：費用低，容易得到對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）擴容效率高反對使用晶體液的理由：平均留駐時間短（只有45min）液體輸入量大造成血清白蛋白的稀釋，血滲透壓降低，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.晶體液復(fù)蘇？贊成使用晶體液的理由：KoustovaE,STheedemaproblemofcrystalloidsiswellknown“Fluidispouredintotheinterstitialspaceonclinicalinformationgainedfromchangesinintravascularspace….…Theend

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

NHLBI終止高張鹽水治療休克的研究NIH所屬的國立心肺血液研究所(NHLBI)已經(jīng)終止了一項有關(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)試驗該試驗旨在研究高張鹽水溶液治療此類患者療效及安全性試驗終止的原因：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）相似

NHLBIHaltsStudyofConcentratedSalineforShockDuetoLackofSurvivalBenefit.AmericanAcademyofEmergencyMedicine

2009-16(3),

MedScapeToday

因生存率下降

NHLBI終止高張鹽水治療休克的研究NIH所液體復(fù)蘇膠體的地位課件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

單獨使用晶體無法維持膠體滲透壓→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COPbalanceessentialforbala

Artery

(Arteriole)動脈,小動脈Vein

(Venule)靜脈,小靜脈PlasmaProtein

ColloidOsmoticPressure膠體滲透壓22mmHg簡化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Artery(Arteriole)Vein(Venu膠體液的作用容量作用：維持血流動力學(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)運抗氧化作用……膠體液的作用容量作用：(colloid)151consecutively

majortraumapatientsWilliamC.Shoemaker

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

majWilliamC.Shoemaker

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

majortraumapatientsWilliamC.ShoemakerOutcomePNormalSubstanceP-1minlaterStudyofCapillaryLeakDirect:ScanningEM:normalendothelialcelljunctionDonaldMcDonald1999NormalSubstanceP-1minlaterCrit

CareMed2006;34:1775–1782CritCareMed2006;34:1775–17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硫醇含量GregoryJ.etc白蛋白增加血漿中抗氧化劑含量GregoryJ.etc.CritCareMed.2004;32:755-759

白蛋白增加血漿中抗氧化劑含量GregoryJ.etc.TheSAFEStudy

Alb:salinedeaths726:729(RR0.99)SimilarneworganfailuresICULOSHospitalLOSVentilatordurationRRTConclusion:OutcomewithalbumininICUnodifferentfromSalineQ:Doesthismeancrystalloidsandcolloidsarethesame?Doesthismeanallcolloidsaresame?Finferetal,NEJM2004;350:2247-56TheSAFEStudy

Alb:salinede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)重癥液體復(fù)蘇的重要性膠體液復(fù)蘇并無優(yōu)勢------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.膠體液復(fù)蘇并無優(yōu)勢------薈萃分析Objective: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.CochraneReport（2008）ObjectiveCochrane

Report（2008）Ascolloidsarenotassociatedwithanimprovementinsurvival,andastheyare

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

Cochrane的名字命名CochraneReport（2008）PerelP,膠體，ICU用，還是不用？膠體，ICU用，還是不用？FluidChallenge

500-100mlcristalloids300-500mlcolloidsover30mincontrolCVPorPAOPandreducespeed/volumeaccordingly

Grade1DSurvivingSepsisCampaign:Internationalguidelinesfor

managementofseveresepsisandsepticshock:2008CritCareMed2008Vol.36,No.1FluidChallenge500-100mlcriFigure.Differences(inpercentagefrombaseline)oftissueoxygentension(ptio2)inthetwovolumegroupsKatrinLang,JoachimBoldt,StefanSuttner,etal.

ColloidsVersusCrystalloidsandTissueOxygenTensioninPatientsUndergoingMajorAbdominalSurgery.AnesthAnalg2001;93:405–9Figure.Differences(inpercen白蛋白對于重癥患者結(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