The value of volume substitution in patients with septic and haemorrhagic shock with respect to the microcirculation.
The value of volume substitution in patients with septic and haemorrhagic shock with respect to the microcirculation.
复制标题
脓毒症和失血性休克患者的容量替代对于微循环的价值。
作者：
M. Siegemund;A. Hollinger;E. C. Gebhard;Jonas D. Scheuzger;D. Bolliger
经过几十年的普通科学兴趣后，脓毒症和失血性休克患者的液体复苏在世纪之交成为重症监护研究的中心舞台。当时，复苏液体是休克患者稳定血流动力学、避免使用血管加压药和治疗低血容量的主要手段，但也伴随着组织过度水肿等不良事件。随着早期目标导向治疗研究的普及，人们意识到复苏液体的类型、容量和时间可能会影响危重患者的病程和结果。同时，微血管血流作为复苏目标的重要性也被接受。如今，曾经被禁用的白蛋白已成为治疗严重脓毒症和脓毒性休克的推荐胶体，并且由于急性肾损伤和死亡率的发生率增加，欧洲医疗机构正在考虑从欧洲市场上移除淀粉溶液。这是前所未有的，特别是因为低分子量淀粉的施用似乎在脓毒症以外的适应症中具有优势，并且因为自阴性淀粉研究以来液体复苏的实践已经发生了根本性的变化。晶体仍然是危重患者低血容量治疗的主要手段，但人们越来越认识到电解质成分、强离子间隙、张力和碳酸氢根取代阴离子可能对不良反应和结果产生影响。在失血性休克中，晶体和胶体的使用正在减少，血浆和红细胞浓缩物在急性出血患者的复苏中变得越来越重要。然而，仍然有一些有影响力的声音警告不要在创伤和失血性休克中随意使用浓缩血浆和红细胞。这篇综述描述了脓毒症、感染性休克和大出血时液体复苏的相关证据。除了基于临床试验的科学证据外，还将说明对微循环以及器官功能可能产生的影响，并强调未来研究的领域。对现有证据的严格评估应该使读者能够为个别患者选择最佳的容量替代。
After decades of ordinary scientific interest, fluid resuscitation of patients with septic and haemorrhagic shock took centre stage in intensive care research at the turn of the millennium. By that time, resuscitation fluids were the mainstay of haemodynamic stabilisation, avoidance of vasopressors and treatment of hypovolaemia in patients in shock, but were accompanied by adverse events such as excessive tissue oedema. With the spread of early goal-directed therapy research intensified and it was realised that type, volume and timing of resuscitation fluids might affect the course and outcome of critically ill patients. At the same time, the importance of microvascular blood flow as target of resuscitation was accepted. Today, once-forbidden albumin is the recommended colloid in severe sepsis and septic shock, and the European Medical Agency is considering the removal of starch solutions from the European market because of an increased incidence of acute kidney injury and mortality. This is unprecedented, especially because the administration of low-molecular-weight starches seems to have advantages in indications other than sepsis, and because practices in fluid resuscitation have changed fundamentally since the negative starch studies. Crystalloids are still the mainstay of hypovolaemia treatment in critically ill patients, but awareness is increasing that electrolyte composition, strong ion gap, tonicity and the bicarbonate-substituting anion may have an effect on adverse effects and outcome. In haemorrhagic shock, the utilisation of crystalloids and colloids is retreating, and plasma and erythrocyte concentrates are gaining more importance in the resuscitation of the patient with acute bleeding. However, there are still influential voices warning against the liberal usage of plasma concentrates and erythrocytes in trauma and haemorrhagic shock. This review describes the evidence relating to fluid resuscitation in sepsis, septic shock and massive haemorrhage. Beside the scientific evidence based on clinical trials, possible effects on the microcirculation and, therefore, organ function will be illustrated and areas of future research highlighted. The critical appraisal of the existing evidence should enable the reader to choose the optimal volume substitution for an individual patient.