Stephens Robert, Mythen Monty
Portex Anaesthesia, Intensive Therapy and Respiratory Medicine Unit, Institute of Child Health, London, UK.
Curr Opin Anaesthesiol. 2003 Aug;16(4):385-92. doi: 10.1097/01.aco.0000084478.59960.76.
Correcting the fluid status of the surgical patient is an integral part of good anaesthetic practice. There have been few areas in anaesthesia and perioperative medicine as controversial as fluid resuscitation. Uncertainties still exist as to what the best solution to give is, whether it be a colloid or a crystalloid, and how and when to give it. As well as increasing awareness of the different properties of various colloids, there has been interest in the nature of the carrier solutions, essentially a choice between saline or Ringer's lactate (compound sodium lactate or Hartmann's solution). In this article we review recent studies involving crystalloids, the 'new colloids', and on the amount and timing of fluid therapy.
Saline based fluids (including most colloids) are associated with a hyperchloremic metabolic acidosis, and a hypocoagulable state, although these may not necessarily harm the patient. Saline may have deleterious effects on renal function. Colloids in solutions similar to Ringer's lactate ('balanced solutions') may avoid these effects although few are currently available. Several studies that have used fluids (along with other therapies) to improve organ perfusion around the time of surgery have been associated with a better outcome.
Compared with Ringer's lactate, saline, and saline-based colloids are associated with a hyperchloremic metabolic acidosis, and a hypocoagulable state although they may not be associated with adverse patient outcomes. Increasing awareness of the 'Stewart hypothesis' has led to new ways of managing hyperchloremic metabolic acidosis. The 'crystalloid-colloid debate' continues, and has led to an awareness that these different fluids, along with their carrier solutions are drugs with different effects. Several studies, in which patients have received more fluid in the protocol group, have found better clinical outcomes in the 'optimized' patients.
纠正外科手术患者的液体状态是良好麻醉实践中不可或缺的一部分。在麻醉和围手术期医学领域，很少有像液体复苏这样存在争议的领域。关于给予何种最佳溶液（无论是胶体还是晶体）以及如何和何时给予，仍然存在不确定性。除了对各种胶体不同特性的认识不断提高外，人们还对载体溶液的性质产生了兴趣，本质上是在生理盐水和乳酸林格氏液（复方乳酸钠或哈特曼氏溶液）之间进行选择。在本文中，我们回顾了近期涉及晶体液、“新型胶体”以及液体治疗的量和时机的研究。
基于生理盐水的液体（包括大多数胶体）与高氯性代谢性酸中毒和低凝状态相关，尽管这些不一定会对患者造成伤害。生理盐水可能对肾功能有有害影响。与乳酸林格氏液类似的溶液中的胶体（“平衡溶液”）可能避免这些影响，尽管目前可用的很少。几项使用液体（以及其他治疗方法）来改善手术前后器官灌注的研究与更好的结果相关。
与乳酸林格氏液相比，生理盐水和基于生理盐水的胶体与高氯性代谢性酸中毒和低凝状态相关，尽管它们可能与不良患者结局无关。对“斯图尔特假说”的认识不断提高，导致了管理高氯性代谢性酸中毒的新方法。“晶体液与胶体液的争论”仍在继续，并使人们意识到这些不同的液体及其载体溶液是具有不同作用的药物。在一些研究中，方案组患者接受了更多液体，结果发现“优化”患者的临床结局更好。
