Albany Medical College, Albany, New York, NY, USA.
Blood Purif. 2010;29(4):331-8. doi: 10.1159/000287776. Epub 2010 Feb 19.
Fluid overload may occur in critically ill patients as a result of aggressive resuscitation therapies. In such circumstances, persistent fluid overload must be avoided since it does not benefit the patient while it may be harmful. In the septic patient, early volume expansion seems to be beneficial. Beyond that threshold, when organ failure develops, fluid overload has been shown to be associated with worse outcomes in multiple disparate studies. One well-designed randomized controlled trial showed the benefit of a conservative fluid management strategy based on limited fluid intake and use of furosemide in such patients. Use of diuretics should be only short term as long as it is effective, generally at high doses, while avoiding simultaneous utilization of nephrotoxins such as aminoglycosides. Multiple randomized controlled trials have not shown benefit in the use of diuretics, either to prevent AKI or to treat established AKI. If fluid overload (defined as fluid accumulation >10% over baseline) develops and the patient does not respond to diuretics, persistent use of these drugs will only lead to a delay in the initiation of dialysis or ultrafiltration and an increased risk of negative patient outcomes. In that setting, early initiation of continuous renal replacement therapies may be preferable.
在危重病患者中，由于积极的复苏治疗，可能会发生液体超负荷。在这种情况下，必须避免持续的液体超负荷，因为它对患者没有益处，反而可能有害。在脓毒症患者中，早期扩容似乎是有益的。超过这个阈值，当器官衰竭发生时，多项不同研究表明液体超负荷与更差的预后相关。一项设计良好的随机对照试验表明，基于限制液体摄入和使用呋塞米的保守液体管理策略对这些患者有益。只要利尿剂有效（通常是高剂量），就应该短期使用利尿剂，同时避免同时使用肾毒性药物，如氨基糖苷类药物。多项随机对照试验表明，利尿剂的使用并不能预防 AKI 或治疗已有的 AKI，也没有益处。如果发生液体超负荷（定义为液体蓄积超过基线的 10%），并且患者对利尿剂没有反应，持续使用这些药物只会导致延迟开始透析或超滤，并增加患者不良结局的风险。在这种情况下，早期开始连续肾脏替代治疗可能更可取。
