外科危重病液體復(fù)蘇策略.pdf
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反映機(jī)體組織灌流缺氧情況和乳酸酸中毒的程度。有臨床
試驗(yàn)表明 ,復(fù)蘇 24h內(nèi)乳酸水平達(dá)到正常值者全部存活;
24～48h內(nèi)達(dá)到正常者 78%存活;超過(guò) 48h者僅 14%存活。
血乳酸正常值為 1～2mmol /L,乳酸可作為機(jī)體低灌注的一
面鏡子 ,其水平升高提示氧債的增加。甚至有人認(rèn)為 ,動(dòng)脈
乳酸正�；悄壳盀橹棺詈玫拇_定復(fù)蘇終點(diǎn)的指標(biāo)之
一[ 19 ]
,優(yōu)于以氧供、 氧耗和 CI作為復(fù)蘇終點(diǎn)。
3 . 4 堿缺失 (BD) 是一個(gè)敏感的反映組織低灌流程度和
時(shí)間的指標(biāo) ,能迅速反映全身組織酸中毒的情況 ,與傷情嚴(yán)
重度和預(yù)后密切相關(guān)。在失血性休克模型中發(fā)現(xiàn) ,BD與氧
債的變化及并發(fā)癥發(fā)生率密切相關(guān)。由于是間接反映血乳
酸水平 ,故在發(fā)生復(fù)雜酸堿紊亂時(shí) ,BD不能準(zhǔn)確反映氧債。
3 . 5 胃黏膜 pH ( pHi) 反映內(nèi)臟或局部組織的灌流狀
態(tài) ,休克期間腸黏膜最先受到影響 ,且在復(fù)蘇后最后恢復(fù)正
常 ,故 pHi能靈敏地幫助判斷復(fù)蘇的終點(diǎn)。pHi的不足在
于胃和血內(nèi) HCO3
-
濃度未必相等 ,其只能間接反映 BL升
高和相伴的酸中毒 ,而且需用特殊的設(shè)備。
參 考 文 獻(xiàn)
[ 1 ] BickellWH,WallMJ, Pepe PE, et al . I mmediate versus delayed
fluid resuscitati on for hypotensive patients with penetrating t ors o
injuries[ J ]. N Engl J Med, 1994, 331 (17) : 1105 - 1109.
[ 2 ] KnoferlMW,AngeleMK,Ayala A, et al . Do different rates of fluid
resuscitation adversely or beneficially influence immune res ponses
after trauma hemorrhage? [ J ]. J Trauma, 1999, 46 (1) : 23 .
[ 3 ] Varela JE, Cohn S M, Diaz I , et al . Sp lanchnic perfusion during
delayed, hypotensive, or aggressive fluid resuscitation from uncon2
trolled hemorrhage[ J ]. Shock, 2003, 20 (5) : 476 - 480.
[ 4 ] Carrillo P, Takasu A, Safar P, et al . Prolonged severe hemorrhagic
shock and resuscitation in rats does not cause subtle brain dam2
age[ J ]. J Trauma, 1998, 45 (2) : 239 - 248.
[ 5 ] 中華醫(yī)學(xué)會(huì)重癥醫(yī)學(xué)分會(huì).成人嚴(yán)重感染與感染性休克血流
動(dòng)力學(xué)監(jiān)測(cè)與支持指南 ( 2006 ) [ J ]. 中國(guó)實(shí)用外科雜志,2007, 27 (1) : 7 - 13.
[ 6 ] Rhee P, Koustova E,Alam HB. Searching for the op timal resuscita2
tion method: Recommendati ons for the initial fluid resuscitati on of
combat casualities[ J ]. J Trauma, 2003, 54 (5, suppl) : S52 - S62 .
[ 7 ] Tremblay LN, Riz oli S B,Brenneman FD. Advances in fluid resus2
citati on of hemorrhagic shock[ J ]. Can J Surg, 2001, 44 ( 3) : 172
- 179.
[ 8 ] Rhee P, Koustova E,Alam HB. Searching for the op timal resuscita2
tion method: Recommendations for the initial fluid resuscition of
combat casualities[ J ]. J Trauma, 2003, 54 (5, Supp l) : S52 - S62 .
[ 9 ] Chiara O, Pel osi P,Brazzi L, et al . Resuscitati on from hemorrhag2
ic shock: experimental model comparing nor mal saline, dextran,and hypertonic saline s olutions[ J ]. Crit CareMed, 2003, 31 (7) :
1915 - 1922.
[ 10 ] Assalia A,Bitteman H, Hirsh T M, et al . Influence of hypertonic
saline on bacterial transl ocation in controlled hemorrhagic shock
[ J ]. Shock, 2001, 15 (4) : 307 - 311.
[ 11 ] Vincent JL,WilkesMM,Navickis RJ . Safety of human albumin2
serious adverse events reported worldwide in 1998 - 2000 [ J ].
Br J Anaesth, 2003, 91 (5) : 625 - 630.
[ 12 ] Cochrane Injuries Gr oup Albumin Reviews Human albumin ad2
ministration in critically ill patients : systematic review of ran2
domized contr olled trials[ J ]. BrMed J, 1998, 317 ( 7153) : 235
- 240.
[ 13 ] Finfer S, Bell omo R, Boyce N, et al . A comparis on of albumin
and saline for fluid resuscitati on in the intensive care unit[ J ]. N
Engl J Med, 2004, 350 (22) : 2247 - 2256.
[ 14 ] Soejima A, Matsuzawa N. Quantitative as well as qualitative
changes of serum albumin in patientswithmalnutrition[ J ]. Ni p2
pon Rinsho, 2005, 63 (1) : 91 - 95.
[ 15 ] Yukl RL,BarOr, HarrisL, et al . Low albumin level in the emer2
gency depart ment : a potential independent p redictor of delayed ......
試驗(yàn)表明 ,復(fù)蘇 24h內(nèi)乳酸水平達(dá)到正常值者全部存活;
24～48h內(nèi)達(dá)到正常者 78%存活;超過(guò) 48h者僅 14%存活。
血乳酸正常值為 1～2mmol /L,乳酸可作為機(jī)體低灌注的一
面鏡子 ,其水平升高提示氧債的增加。甚至有人認(rèn)為 ,動(dòng)脈
乳酸正�；悄壳盀橹棺詈玫拇_定復(fù)蘇終點(diǎn)的指標(biāo)之
一[ 19 ]
,優(yōu)于以氧供、 氧耗和 CI作為復(fù)蘇終點(diǎn)。
3 . 4 堿缺失 (BD) 是一個(gè)敏感的反映組織低灌流程度和
時(shí)間的指標(biāo) ,能迅速反映全身組織酸中毒的情況 ,與傷情嚴(yán)
重度和預(yù)后密切相關(guān)。在失血性休克模型中發(fā)現(xiàn) ,BD與氧
債的變化及并發(fā)癥發(fā)生率密切相關(guān)。由于是間接反映血乳
酸水平 ,故在發(fā)生復(fù)雜酸堿紊亂時(shí) ,BD不能準(zhǔn)確反映氧債。
3 . 5 胃黏膜 pH ( pHi) 反映內(nèi)臟或局部組織的灌流狀
態(tài) ,休克期間腸黏膜最先受到影響 ,且在復(fù)蘇后最后恢復(fù)正
常 ,故 pHi能靈敏地幫助判斷復(fù)蘇的終點(diǎn)。pHi的不足在
于胃和血內(nèi) HCO3
-
濃度未必相等 ,其只能間接反映 BL升
高和相伴的酸中毒 ,而且需用特殊的設(shè)備。
參 考 文 獻(xiàn)
[ 1 ] BickellWH,WallMJ, Pepe PE, et al . I mmediate versus delayed
fluid resuscitati on for hypotensive patients with penetrating t ors o
injuries[ J ]. N Engl J Med, 1994, 331 (17) : 1105 - 1109.
[ 2 ] KnoferlMW,AngeleMK,Ayala A, et al . Do different rates of fluid
resuscitation adversely or beneficially influence immune res ponses
after trauma hemorrhage? [ J ]. J Trauma, 1999, 46 (1) : 23 .
[ 3 ] Varela JE, Cohn S M, Diaz I , et al . Sp lanchnic perfusion during
delayed, hypotensive, or aggressive fluid resuscitation from uncon2
trolled hemorrhage[ J ]. Shock, 2003, 20 (5) : 476 - 480.
[ 4 ] Carrillo P, Takasu A, Safar P, et al . Prolonged severe hemorrhagic
shock and resuscitation in rats does not cause subtle brain dam2
age[ J ]. J Trauma, 1998, 45 (2) : 239 - 248.
[ 5 ] 中華醫(yī)學(xué)會(huì)重癥醫(yī)學(xué)分會(huì).成人嚴(yán)重感染與感染性休克血流
動(dòng)力學(xué)監(jiān)測(cè)與支持指南 ( 2006 ) [ J ]. 中國(guó)實(shí)用外科雜志,2007, 27 (1) : 7 - 13.
[ 6 ] Rhee P, Koustova E,Alam HB. Searching for the op timal resuscita2
tion method: Recommendati ons for the initial fluid resuscitati on of
combat casualities[ J ]. J Trauma, 2003, 54 (5, suppl) : S52 - S62 .
[ 7 ] Tremblay LN, Riz oli S B,Brenneman FD. Advances in fluid resus2
citati on of hemorrhagic shock[ J ]. Can J Surg, 2001, 44 ( 3) : 172
- 179.
[ 8 ] Rhee P, Koustova E,Alam HB. Searching for the op timal resuscita2
tion method: Recommendations for the initial fluid resuscition of
combat casualities[ J ]. J Trauma, 2003, 54 (5, Supp l) : S52 - S62 .
[ 9 ] Chiara O, Pel osi P,Brazzi L, et al . Resuscitati on from hemorrhag2
ic shock: experimental model comparing nor mal saline, dextran,and hypertonic saline s olutions[ J ]. Crit CareMed, 2003, 31 (7) :
1915 - 1922.
[ 10 ] Assalia A,Bitteman H, Hirsh T M, et al . Influence of hypertonic
saline on bacterial transl ocation in controlled hemorrhagic shock
[ J ]. Shock, 2001, 15 (4) : 307 - 311.
[ 11 ] Vincent JL,WilkesMM,Navickis RJ . Safety of human albumin2
serious adverse events reported worldwide in 1998 - 2000 [ J ].
Br J Anaesth, 2003, 91 (5) : 625 - 630.
[ 12 ] Cochrane Injuries Gr oup Albumin Reviews Human albumin ad2
ministration in critically ill patients : systematic review of ran2
domized contr olled trials[ J ]. BrMed J, 1998, 317 ( 7153) : 235
- 240.
[ 13 ] Finfer S, Bell omo R, Boyce N, et al . A comparis on of albumin
and saline for fluid resuscitati on in the intensive care unit[ J ]. N
Engl J Med, 2004, 350 (22) : 2247 - 2256.
[ 14 ] Soejima A, Matsuzawa N. Quantitative as well as qualitative
changes of serum albumin in patientswithmalnutrition[ J ]. Ni p2
pon Rinsho, 2005, 63 (1) : 91 - 95.
[ 15 ] Yukl RL,BarOr, HarrisL, et al . Low albumin level in the emer2
gency depart ment : a potential independent p redictor of delayed ......
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