休克補液辯論：晶體液首選

晶體液

VS

膠體液Crystalloids

VS

Colloids1，液體種類的選擇2，復(fù)蘇策略（量）3，復(fù)蘇程度endpoints（度）液體復(fù)蘇包括三個主題晶體液膠體液Design:Systematicreviewofrandomisedcontrolledtrialscomparingadministrationofalbuminorplasmaproteinfractionwithnoadministrationorwithadministrationofcrystalloidsolutionincriticallyillpatientswithhypovolaemia,burns,orhypoalbuminaemia.Subjects:30randomisedcontrolledtrialsincluding1419randomisedpatients.Sesults：Pooleddifferenceintheriskofdeathwithalbuminwas6%(95%confidenceinterval3%to9%)withafixedeffectsmodel.Thesedatasuggestthatforevery17criticallyillpatientstreatedwithalbuminthereisoneadditionaldeath.Conclusions:Thereisnoevidencethatalbuminadministrationreducesmortalityincriticallyillpatientswithhypovolaemia,burns,orhypoalbuminaemiaandastrongsuggestionthatitmayincreasemortality.Conclusion:Albuminincreasetheriskofmortalityby6%Design:Systematicreviewofrandomisedcontrolledtrialsofresuscitationwithcolloidscomparedwithcrystalloidsforvolumereplacementofcriticallyillpatients.Subjects:37randomisedcontrolledtrialsTypeofinjury:Trauma,Burns,Surgery,Septicandhypovolaemicshock,ARDS,VascularleaksyndromeDesign:Systematicreviewofrandomisedcontrolledtrialsofresuscitationwithcolloidscomparedwithcrystalloidsforvolumereplacementofcriticallyillpatients;analysisstratifiedaccordingtopatienttypeandqualityofallocationconcealment.Subjects:37randomisedcontrolledtrialswereeligible,ofwhich26unconfoundedtrialscomparedcolloidswithcrystalloids(n=1622).(The10trialsthatcomparedcolloidinhypertoniccrystalloidwithisotoniccrystalloid(n=1422)andonetrialthatcomparedcolloidinisotoniccrystalloidwithhypertoniccrystalloid(n=38)aredescribedinthelongerversiononourwebsite).1998-2004CommentsinBMJSAFE研究:4%AlbuminvsNormalSaline（SalineversusAlbuminFluidEvaluation）雙盲隨機對照，28天死亡率評估澳大利亞新西蘭16個ICU，共6997個病人NEnglJMed2004;350(22):2247-2256(n=3497)(n=3500)28天病死率不同病人群體亞組分析AlbuminNSRR(95%CI)p創(chuàng)傷(N=1186)13.610.01.36(0.99-1.86)0.06

伴顱腦傷24.515.11.62(1.12-2.34)0.01(N=492)不伴顱腦傷6.26.21.00(0.56-1.79)1.00(N=694)Trauma亞組分析VISEPStudy(HESvsRinger’slactate)

EfficacyofVolumeSubstitutionandInsulinTherapyinSevereSepsisVISEPStudy(HESvsRinger’slactate)

Subjects：Patientsweredeemedtobeeligibleiftheonsetofthesyndromewaslessthan24hoursbeforeadmissiontotheICUorlessthan12hoursafteradmissioniftheconditiondevelopedintheICU.HESgroup：HESuntilalimitof20mL/kg/day,thenpreferentiallyRinger’sorothernon-colloidfluidsRLgroup：Ringer’slactateVISEPStudy(HESvsRinger’slactate)

VISEPStudy(HESvsRinger’slactate)

VISEPStudy(HESvsRinger’slactate)

P=0.007betweenHESdosesP=0.345betweenRinger‘slactatedosesVISEPStudy(HESvsRinger’slactate)

VISEPStudy(HESvsRinger’slactate)

Theneedforrenal-replacementtherapyand90-daymortalityweresignificantlycorrelatedwiththecumulativedoseofHES(P<0.001andP=0.001,respectively)butnotwiththedoseofRinger’slactate(P=0.11andP=0.31,respectively).60402000-24h24-48hHemohesml/kg/BW/24h22ml/kg/BW28,274最初24hours內(nèi)38,2100研究期間至少有一天%nn=262VISEPStudy(HESvsRinger’slactate)

57.6%30.9%0%25%50%75%22.8%33.0%0%25%50%75