Choice of Fluid Therapy in the Initial Management of Sepsis, Severe Sepsis, and Septic Shock.
Choice of Fluid Therapy in the Initial Management of Sepsis, Severe Sepsis, and Septic Shock.
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DOI：
10.1097/shk.0000000000000577
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发表时间：
2016-07
期刊：
影响因子：
--
通讯作者：
Holcomb JB
中科院分区：
文献类型：
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作者：
Chang R;Holcomb JB
脓毒症导致内皮糖萼层的破坏和微血管的损伤，导致液体的间质积聚和随后的水肿。液体复苏是脓毒症初始治疗的主要方法，但液体的选择尚不清楚。理想的复苏液体是恢复血管内容量同时最小化水肿的液体;不幸的是，水肿和水肿相关并发症是当前复苏策略的常见后果。晶体被推荐作为一线治疗，但晶体的类型没有规定。越来越多的证据表明，生理盐水与死亡率增加和肾损伤有关;平衡晶体可能是一种更安全的替代品。白蛋白在脓毒症人群中的结局与晶体相似，但成本更高。羟乙基淀粉似乎会增加危重患者的死亡率和肾损伤，不再适用于这些患者。在创伤人群中，在出血性休克治疗中减少晶体和胶体的使用，转向基于血浆的复苏，导致炎症和水肿介导的并发症减少。需要进行研究以确定在脓毒症的情况下，类似的复苏策略是否也会产生这些益处。
Sepsis results in disruption of the endothelial glycocalyx layer and damage to the microvasculature, resulting in interstitial accumulation of fluid and subsequently edema. Fluid resuscitation is a mainstay in the initial treatment of sepsis, but the choice of fluid is unclear. The ideal resuscitative fluid is one which restores intravascular volume while minimizing edema; unfortunately, edema and edema-related complications are common consequences of current resuscitation strategies. Crystalloids are recommended as first-line therapy, but the type of crystalloid is not specified. There is increasing evidence that normal saline is associated with increased mortality and kidney injury; balanced crystalloids may be a safer alternative. Albumin is similar to crystalloids in terms of outcomes in the septic population but is costlier. Hydroxyethyl starches appear to increase mortality and kidney injury in the critically ill and are no longer indicated in these patients. In the trauma population, the shift to plasma-based resuscitation with decreased use of crystalloid and colloid in the treatment of hemorrhagic shock has led to decreased inflammatory and edema-mediated complications. Studies are needed to determine if these benefits also occur with a similar resuscitation strategy in the setting of sepsis.