Adult Critical Care Unit and Department of Renal Medicine and Transplantation, The Royal London Hospital, Barts Health NHS Trust, London, UK.
Curr Opin Crit Care. 2013 Aug;19(4):308-14. doi: 10.1097/MCC.0b013e3283632e29.
To review recent studies and information on the relationship between fluid administration and kidney function in critically ill patients.
There is little evidence from large multicenter trials to direct fluid therapy in patients at risk of acute kidney injury (AKI). Evidence of benefit for fluid administration from single center studies of fluid resuscitation to hemodynamic goals needs to be weighed against evidence of harm associated with fluid overload in large observational studies. The composition of intravenous fluid may affect the risk of AKI. Even latest-generation hydroxyethyl starches increase the risk of severe AKI in general and septic ICU patients. Isotonic saline has been associated with greater incidence of AKI in comparison to buffered crystalloids. Experimentally, infusion of saline results in reduction in renal perfusion in comparison to buffered solutions.
Clinicians need to weigh the balance between adequate resuscitation of cardiac output and avoidance of fluid overload. Protocolized resuscitation to hemodynamic goals may help achieve these conflicting goals at least in the early phases of critical illness. In critically ill patients with, or at risk of, AKI, clinicians should avoid starch and, possibly, saline solutions.
回顾最近关于危重症患者液体管理与肾功能之间关系的研究和信息。
对于有急性肾损伤 (AKI) 风险的患者，大型多中心试验几乎没有证据可以直接指导液体治疗。需要权衡来自单一中心的针对血流动力学目标的液体复苏研究中液体给予的益处证据，以及与大型观察性研究中与液体超负荷相关的危害证据。静脉输液的成分可能会影响 AKI 的风险。即使是最新一代羟乙基淀粉也会增加一般和脓毒症 ICU 患者严重 AKI 的风险。与缓冲晶体液相比，生理盐水与更高的 AKI 发生率相关。实验中，与缓冲溶液相比，输注生理盐水会导致肾灌注减少。
临床医生需要权衡心输出量充分复苏与避免液体超负荷之间的平衡。针对血流动力学目标的方案性复苏至少可以在危重病的早期阶段帮助实现这些相互冲突的目标。对于有或有 AKI 风险的危重症患者，临床医生应避免使用淀粉类药物，可能还应避免使用生理盐水。
