Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
Crit Care Med. 2013 Apr;41(4):972-81. doi: 10.1097/CCM.0b013e31827466d2.
To evaluate the efficacy and safety of liberal fluid resuscitation of adults with severe malaria. DESIGN, SETTING, PATIENTS, AND METHODS: Twenty-eight Bangladeshi and Indian adults with severe falciparum malaria received crystalloid resuscitation guided by transpulmonary thermodilution (PiCCO) in an intensive care setting. Systemic hemodynamics, microvascular indices and measures of acidosis, renal function, and pulmonary edema were followed prospectively.
All patients were hypovolemic (global end-diastolic volume index<680 mL/m) on enrollment. Patients received a median (range) 3230 mL (390-7300) of isotonic saline in the first 6 hours and 5450 mL (710-13,720) in the first 24 hours. With resuscitation, acid-base status deteriorated in 19 of 28 (68%), and there was no significant improvement in renal function. Extravascular lung water increased in 17 of 22 liberally resuscitated patients (77%); eight of these patients developed pulmonary edema, five of whom died. All other patients survived. All patients with pulmonary edema during the study were hypovolemic or euvolemic at the time pulmonary edema developed. Plasma lactate was lower in hypovolemic patients before (rs=0.38; p=0.05) and after (rs=0.49; p=0.01) resuscitation but was the strongest predictor of mortality before (chi-square=9.9; p=0.002) and after resuscitation (chi-square=11.1; p<0.001) and correlated with the degree of visualized microvascular sequestration of parasitized erythrocytes at both time points (rs=0.55; p=0.003 and rs=0.43; p=0.03, respectively). Persisting sequestration was evident in 7 of 15 patients (47%) 48 hours after enrollment.
Lactic acidosis--the strongest prognostic indicator in adults with severe falciparum malaria--results from sequestration of parasitized erythrocytes in the microcirculation, not from hypovolemia. Liberal fluid resuscitation has little effect on this sequestration and does not improve acid-base status or renal function. Pulmonary edema--secondary to increased pulmonary vascular permeability--is common, unpredictable, and exacerbated by fluid loading. Liberal fluid replacement of adults with severe malaria should be avoided.
评估严重疟疾成人患者进行自由液体复苏的疗效和安全性。
设计、地点、患者和方法：28 名孟加拉国和印度的严重恶性疟原虫疟疾成人患者在重症监护病房接受经肺热稀释（PiCCO）指导的晶体液复苏。系统血流动力学、微血管指数以及酸中毒、肾功能和肺水肿的指标均进行前瞻性检测。
所有患者入组时均存在低血容量（全身舒张末期容积指数<680mL/m）。在最初 6 小时内，患者中位（范围）接受 3230mL（390-7300）的等渗盐水，在最初 24 小时内接受 5450mL（710-13720）的等渗盐水。在复苏过程中，19/28（68%）例患者酸碱状态恶化，肾功能无明显改善。17/22 例接受自由液体复苏的患者出现血管外肺水增加（77%）；其中 8 例发生肺水肿，5 例死亡。所有其他患者存活。在研究期间出现肺水肿的所有患者在发生肺水肿时均处于低血容量或血容量正常状态。复苏前（rs=0.38；p=0.05）和复苏后（rs=0.49；p=0.01），低血容量患者的血浆乳酸水平更低，但在复苏前（卡方=9.9；p=0.002）和复苏后（卡方=11.1；p<0.001）均为最强的死亡预测因子，与两个时间点的寄生虫红细胞微血管隔离程度相关（rs=0.55；p=0.003 和 rs=0.43；p=0.03）。入组后 48 小时，15 例患者中有 7 例（47%）仍存在持续隔离。
乳酸酸中毒——严重恶性疟原虫疟疾成人患者最强的预后指标——是由寄生虫红细胞在微循环中的隔离引起的，而不是由低血容量引起的。自由液体复苏对这种隔离几乎没有影响，也不能改善酸碱状态或肾功能。肺水肿——继发于肺血管通透性增加——很常见，不可预测，液体负荷会加重。应避免对严重疟疾成人患者进行自由液体替代。
