Targeted resuscitation strategies after injury.
Targeted resuscitation strategies after injury.
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DOI：
10.1097/01.ccx.0000144771.96342.2c
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发表时间：
2004-12-01
影响因子：
3.3
通讯作者：
Horst, H Matilda
中科院分区：
文献类型：
--
作者：
Bilkovski, Robert N;Rivers, Emanuel P;Horst, H Matilda
审查目的：尽管创伤的发病率和死亡率一直居高不下，但在过去的半个世纪，创伤患者的治疗已经取得了进展。创伤患者的治疗需要及时干预和损害控制，以维持正常的血流动力学参数和充分的全身灌注。在氧气的输送和消耗之间有一个很好的平衡，当这个平衡被扰乱时，可能会产生氧债。持续存在的氧债是相当有害的，导致炎症级联反应，可导致多系统器官功能障碍。快速识别和恢复氧债是危重病人复苏的核心，无论是败血症还是创伤的结果。最近的发现：复苏终点已经发展，使医生能够更迅速地识别氧输送和消耗之间的扰动。此外，终点可以统一衡量复苏的充分性：防止复苏不足和过度复苏，并作为基础，比较复苏试验的结果措施。最近的技术进步已经允许通过侵入性较小的手段获得更丰富的临床数据。这方面的例子包括食管多普勒监测、舌下二氧化碳监测、正交偏振光谱成像和锂稀释心输出量测定。这些器械可与更传统的复苏终点（即乳酸和碱缺乏）配合使用，以最大限度地增加氧气输送并纠正组织缺氧。此外，失血性休克的治疗也在不断发展，并挑战着正常血压复苏的教条做法。本文综述了（1）复苏终点以优化心功能，（2）复苏终点以评估微循环，（3）扩张性失血性休克治疗的最新进展，以及（4）将早期目标导向治疗从感染性休克转化为创伤治疗。过去的研究结果反映和未来的研究方向和临床实践的基础上，最近的临床进展。
PURPOSE OF REVIEW: The management of the traumatically injured patient has evolved during the past half century despite continually high morbidity and mortality rates. The management of the trauma victim requires timely intervention and damage control in an attempt to maintain normal hemodynamic parameters and adequate systemic perfusion. There is a fine balance between oxygen delivery and consumption, and when this is perturbed, oxygen debt may ensue. The presence of ongoing oxygen debt is rather deleterious, resulting in an inflammatory cascade that can lead to multisystem organ dysfunction. The rapid identification and restoration of oxygen debt are central to the resuscitation of the critically ill patient, be it the result of sepsis or trauma.RECENT FINDINGS: Resuscitation end points have evolved that allow the physician to more rapidly identify a perturbation between oxygen delivery and consumption. Moreover, end points allow uniformity in gauging the adequacy of resuscitation: preventing under- and overresuscitation and serving as a basis to compare outcome measures in resuscitation trials. Recent technologic advances have allowed a greater wealth of clinical data that can be obtained via less invasive means. Examples of this include esophageal Doppler monitoring, sublingual capnography, orthogonal polarization spectral imaging, and lithium dilution cardiac output determinations. These devices can be used in concert with more traditional resuscitation end points (ie, lactate and base deficit) to maximize oxygen delivery and correct tissue dysoxia. In addition, the management of hemorrhagic shock is continuing to evolve and challenge the dogmatic practices of normotensive resuscitation.SUMMARY: This review addresses (1) resuscitation end points to optimize cardiac function, (2) resuscitation end points to assess the microcirculation, (3) recent developments in the management of hypotensive hemorrhagic shock, and (4) the translation of early goal-directed therapy from septic shock to use in trauma. Past findings are reflected on and direction for future investigation and clinical practice based on recent clinical advances is provided.