关注危重病人液体平衡(定稿).ppt

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1、关注危重病人液体平衡徐颖鹤目录EGDT提高抢救成功率液体超负荷增加危重病人死亡率CVP监测能准确指导液体复苏吗？白蛋白用于液体复苏新观点EarlyGoal-DirectedTherapy(EGDT):involvesadjustmentsofcardiacpreload,afterload,andcontractilitytobalanceO2deliverywithO2demandChest1992;101:1644.EarlyGoal-DirectedTherapyintheTreatmentofSevereSepsisandSepticShockRiversE,NguyenB,Havs

2、tadS,etal.Earlygoal-directedtherapyinthetreatmentofseveresepsisandsepticshock.NEJM2001;345:1368.Studypurpose:toevaluatetheefficacyofearlygoal-directedtherapyinpatientspresentingtoanemergencydepartmentwithseveresepsisorsepticshock(priortoICUadmission)Studydesign:prospective,randomizedcontrolled,part

3、iallyblinded,singlecentertrialPatientrandomizedN=263EarlygoaldirectedtherapyN=130StandardtherapyN=133CVP>8-12mmHgMAP>65mmHgUrineOutput>0.5ml/kg/hrCVP>8-12mmHgMAP>65mmHgUrineOutput>0.5ml/kg/hrScvO2>70%SaO2>93%Hct>30%AntibioticsgivenatdiscretionoftreatingcliniciansAssoonaspossibleMean6.2hrsICUMDsbli

4、ndedtostudytreatmentNEJM2001;345:1368-77.Atleast6hoursofEGDTMean8hrsTransfertoICUCVP:centralvenouspressureMAP:meanarterialpressureScvO2:centralvenousoxygensaturationEarlyGoal-DirectedTherapyNEJM2001;345:1368-77.49.2%33.3%0102030405060StandardTherapyN=133EGDTN=130P=0.01**KeydifferencewasinsuddenCVco

5、llapse,notMODSEarlyGoal-DirectedTherapyResults:28DayMortalitySuddenCVCollapseMODS21%vs10%p=0.0222%vs16%P=0.27NEJM2001;345:1368-77.Mortality质疑点质疑点质疑点CVP监测能准确指导液体复苏吗？Objective:Asystematicreviewoftheliteraturetodeterminethefollowing:therelationshipbetweenCVPandbloodvolume,theabilityofCVPtopredictflui

6、dresponsiveness,theabilityofthechangeinCVP(CVP)topredictfluidresponsiveness.ThepooledcorrelationcoefficientbetweentheCVPandmeasuredbloodvolumewas0.16(95%CI,0.03to0.28;r=0.02).1、ThepooledcorrelationcoefficientbetweenbaselineCVPandchangeinstrokeindex/cardiacindexwas0.182、ThepooledareaundertheROCcurve

7、was0.563、ThepooledcorrelationbetweenCVPandchangeinstrokeindex/cardiacindexwas0.114、ThebaselineCVPwas8.7-2.3mmHgintheresponders,ascomparedto9.7-2.2mmHginnonresponders(notsignficant;p0.3).结论1、CVP与血容量之间相关性很低2、