1、目标导向液体治疗Goal - directed fluid therapy复旦大学附属中山医院麻醉科薛张纲液体治疗的基本策略（1） Moore（1959）外科创伤应激反应应激激素水钠潴留围手术期应当限制液体输入 Shires（1961）液体治疗的基本策略（2）大手术液体转移第三间隙细胞外液减少用晶体液补充第三间隙液体的丢失?液体治疗的基本策略（3）1.生理需要量：晶体液2.术前液体丧失量：晶体液3.液体再分布：晶体液4.麻醉后血管扩张：晶体液或（和）胶体液5.术中失血：晶体液、胶体液和血制品是麻醉科医生输液的准则，但合理吗？主张限制输液者认为避免大量的液体进入组织间隙降低心肺并发症及伤口感染发
2、生率加速胃肠道功能的恢复缩短住院时间降低并发症的发生率与死亡率Lobo DN, et al. Lancet 2002; 359: 181218Joshi GP. Anesth Analg. 2005; 101: 601Brandstrup B. Ann Surg. 2003; 238: 641 648主张开放输液者认为保证有效的组织灌注术中循环稳定术后恶心、呕吐减少术后康复加速Holte K, et al. Ann Surg, 2004; 240: 892Ali SZ, et al. Anaesthesia, 2003, 58, 775803 48例ASA 1-2级病人，接受LC手术分成开放输
3、液和限制输液组开放40 ml/kg LR限制15 ml/kg LR观察指标呼吸、运动能力、心血管激素反应、疼痛、恶心和呕吐、康复和住院时间支持开放输液者的观点Holte K, et al. Liberal Versus Restrictive Fluid Administration to Improve Recovery After Laparoscopic Cholecystectomy, A Randomized, Double-Blind Study. Annals of Surgery, 2004, 240(5): 892-899.开放输液组术后进食早，手术当天符合出院标准和出院人数
4、明显大于限制输液组Holte K, et al. Liberal Versus Restrictive Fluid Administration to Improve Recovery After Laparoscopic Cholecystectomy, A Randomized, Double-Blind Study. Annals of Surgery, 240(5): 892-899.开放输液组术后肺功能和运动能力都明显优于限制输液组Holte K, et al. Liberal Versus Restrictive Fluid Administration to Improve Re
5、covery After Laparoscopic Cholecystectomy, A Randomized, Double-Blind Study. Annals of Surgery, 2004, 240(5): 892-899.然而，术中输液过多可以导致组织水肿临床液体治疗的最终目的是术中液体治疗的最终目标是避免输液不足引起的隐匿性低血容量和组织低灌注，及输液过多引起的心功能不全和外周组织水肿必须保证满意的血容量和适宜的麻醉深度，对抗手术创伤可能引起的损害，保证组织灌注满意，器官功能正常Important perioperative aim: Avoidance of edemaExa
6、mple: Abdominal hypertension 20 例正常的病人，行大肠手术分组标准液体输注（3 L, 1 L NS, 2 L 5% GS）限制液体输注（2 L, 0.5 L NS, 1.5 L 5%GS）比较终点体重、尿量、电解质、胃肠动力和其它并发症主张限制输液者的观点（1）Lobo DN, et al. Effect of salt and water balance on recovery of gastrointestinal function after elective colonic resection: a randomised controlled trial.
7、 Lancet 2002; 359: 181218体重静脉补液量入液总量尿钠排出量两组并发症和30天死亡人数比较两组固体和液体食物排空时间比较两组病人终点事件的比较0.00136.0（5.0 7.0）9.0（7.814.3）术后住院时间（天）0.00224.0（4.0 4.3）6.5（5.5 7.0）恢复固体食物（天）0.00124.0（3.8 4.0）6.0（4.8 6.3）停止静脉输液（天）0.00134.0（3.0 4.0）6.5（5.8 8.0）首次排便（天）0.00123.0（2.0 3.0）4.0（4.0 5.0）首次肛门排气（天）P值差异限制组标准组终点主张限制输液者的观点（3）
8、病人总数141例，加入随机、双盲对照研究围术期液体治疗分成限制输液和常规输液组限制输液组各种并发症发生率降低心、肺并发症7% vs 24%组织愈合并发症16% vs 31%死亡率0 vs 4.7%结论：择期结直肠手术围术期限制输液有利Brandstrup B, Pott F, et al: Effects of Intravenous Fluid Restriction on Postoperative Complications: Comparison of Two Perioperative Fluid Regimens. A Randomized Assessor-Blinded Mul
9、ticenter Trial. Annals of Surgery, 2003,238, 641 648.术中限制入液量硬膜外麻醉无液体负荷没有第三间隙丢失液的标准替代物失血替代物HES 1:1术后引流失液量可以HES术后根据体重计算补液量术后优先考虑经口补液择期结直肠手术限制静脉入液量Brandstrup et al., Ann Surg 2003; 238: 641-648择期结直肠手术限制静脉入液量Brandstrup et al., Ann Surg 2003; 238: 641-648升补充液体经口补充液体静脉补充0.9%的盐水静脉补充5%葡萄糖静脉补充HAES 6%静脉补充其他或非
10、特异性液体术后期Day 1 Day 2 Day 3 Day 4 Day 5 Day 67,06,05,04,03,02,01,00R S R SR S R SR S R S R S*R = 限量组S = 标准组生理盐水公斤体重变化情况术后Day 1 Day 2 Day 3 Day 4 Day 5 Day 67,06,05,04,03,02,01,00R S R SR S R SR S R S R S*R =限量组S =标准组择期结直肠手术限制静脉入液量Brandstrup et al., Ann Surg 2003; 238: 641-648静脉补液和体重增加的相关并发症n=51 n=48 n
11、=42n=40 n=52 n=43并发症发生率（% %）10090807060504030201005.5 L 2.5 kgn=52 n=43输入液体量增加体重择期结直肠手术限制静脉入液Brandstrup et al., Ann Surg 2003; 238: 641-648EdemaGlycocalyx?Rehm M et al. Anesthesiology 2001; 95: 849-856.GlycocalyxJacob M, et al. Anesthesiology. 2006; 104:1223-31.GlycocalyxEndothelial injury following
12、 volumeoverloadingFluidoverloadhastobeavoided!The authors concluded that the volume overload may have deleterious effects on anastomotic healing and post-operative complications in GI surgery, possible because of a marked bowel wall edema. Ann. Surg. 2009; 249(2):181-5 The key to better intravenous
13、fluid therapy is to give the right amount of the right fluid at the right time and to try and maintain the patient in a state of zero fluid balance as much as possible Avoidance of fluid overload, rather than fluid restriction, seems to be the key to better postoperative outcome.Lobo DN. Ann Surg. 2
14、009 Feb; 249(2): 186-8围手术期液体治疗的影响因素及预后有关液体治疗的推论液体过量有害液体不足同样有害猜测往往会误导临床医生，应当评估而不是猜测液体治疗应采取个体化的原则 Goal Directed Fluid Therapy：using more patient data and fewer assumptions 100例病人，随机分成常规输液和目标控制输液组目标控制输液经食管多普勒监测指导术中补液（FTc, SV） 6% HES以200 ml增加，以达到最佳心排血量进食固体食物的时间分别为4.7 0.5 vs 3.0 0.5天住院时间分别为7 3 vs 5 3天术后需要治疗的严重PONV分别为36% vs 14%Gan TJ, et al: Goal-directed Intraoperative Fluid Administration Reduces Length of Hospital Stay after Major Surgery. Anesthesiology 2002; 97: 8206.目标导向液体治疗使用Doppler指导液体输注
