休克补液辩论晶体液首选.ppt

晶体液 VS 胶体液;1，液体种类的选择 2，复苏策略（量） 3，复苏程度endpoints （度） ;晶体液;Design: Systematic review of randomised controlled trials comparing administration of albumin or plasma protein fraction with no administration or with administration of crystalloid solution in critically ill patients with hypovolaemia, burns, or hypoalbuminaemia. Subjects: 30 randomised controlled trials including1419 randomised patients. ;Sesults： Pooled difference in the risk of death with albumin was 6% (95% confidence interval 3% to 9%) with a fixed effects model. These data suggest that for every 17 critically ill patients treated with albumin there is one additional death. Conclusions: There is no evidence that albumin administration reduces mortality in critically ill patients with hypovolaemia, burns, or hypoalbuminaemia and a strong suggestion that it may increase mortality. Conclusion: Albumin increase the risk of mortality by 6%;Design: Systematic review of randomised controlled trials of resuscitation with colloids compared with crystalloids for volume replacement of critically ill patients. Subjects: 37 randomised controlled trials Type of injury: Trauma, Burns, Surgery, Septic and hypovolaemic shock, ARDS, Vascular leak syndrome;1998-2004 Comments in BMJ;SAFE研究: 4% Albumin vs Normal Saline （Saline versus Albumin Fluid Evaluation） 双盲随机对照，28天死亡率评估 澳大利亚新西兰16个ICU，共6997个病人;N Engl J Med 2004;350(22):2247-2256;不同病人群体亚组分析; Albumin NS RR ( 95% CI ) p;;;VISEP Study (HES vs Ringer’s lactate) ;VISEP Study (HES vs Ringer’s lactate) ;VISEP Study (HES vs Ringer’s lactate) ;VISEP Study (HES vs Ringer’s lactate) ;;;VISEP Study (HES vs Ringer’s lactate) ;;;VISEP Study (HES vs Ringer’s lactate) ;;;;胶体液应用的副作用有不少报道，不同的胶体液副作用不一，白蛋白相对好些（Vincent JL. Relevance of albumin in modern critical care medicine. Best Pract Res Clin Anaesthesiol 2009; 23:183–191，这篇文章强调白蛋白不应该用于容量复苏） 右旋糖苷（Dextrans）副作用：肾损害、影响凝血功能、过敏反应 明胶（Gelatin）：对肾功能和凝血功能影响相对小，但是过敏反应发生率在合成胶体液中是最高的，同时由于肾滤过快半衰期短，容量复苏效