Raghunathan K, Murray P T, Beattie W S, Lobo D N, Myburgh J, Sladen R, Kellum J A, Mythen M G, Shaw A D
Duke University Medical Center, Division of Veterans Affairs, Durham, NC 27710, USA.
School of Medicine and Medical Science, University College Dublin, Dublin, Ireland
Br J Anaesth. 2014 Nov;113(5):772-83. doi: 10.1093/bja/aeu301.
Fluid management during critical illness is a dynamic process that may be conceptualized as occurring in four phases: rescue, optimization, stabilization, and de-escalation (mobilization). The selection and administration of resuscitation fluids is one component of this complex physiological sequence directed at restoring depleted intravascular volume. Presently, the selection of i.v. fluid is usually dictated more by local practice patterns than by evidence. The debate on fluid choice has primarily focused on evaluating outcome differences between 'crystalloids vs colloids'. More recently, however, there is interest in examining outcome differences based on the chloride content of crystalloid solutions. New insights into the conventional Starling model of microvascular fluid exchange may explain that the efficacy of colloids in restoring and maintaining depleted intravascular volume is only moderately better than crystalloids. A number of investigator-initiated, high-quality, randomized controlled trials have demonstrated that modest improvements in short-term physiological endpoints with colloids have not translated into better patient-centred outcomes. In addition, there is substantial evidence that certain types of fluids may independently worsen patient-centred outcomes. These include hydroxyethyl starch and albumin solutions in selected patient populations. There is no evidence to support the use of other colloids. The use of balanced salt solutions in preference to 0.9% saline is supported by the absence of harm in large observational studies. However, there is no compelling randomized trial-based evidence demonstrating improved clinical outcomes with the use of balanced salt solutions compared with 0.9% saline at this time.
危重症期间的液体管理是一个动态过程，可分为四个阶段：复苏、优化、稳定和降级（动员）。复苏液体的选择和使用是这一旨在恢复血管内血容量的复杂生理过程的一部分。目前，静脉输液的选择更多地取决于当地的实践模式，而非证据。关于液体选择的争论主要集中在评估“晶体液与胶体液”之间的疗效差异。然而，最近人们开始关注基于晶体液氯化物含量的疗效差异。对传统的微血管液体交换斯塔林模型的新见解可能解释了，胶体液在恢复和维持血管内血容量方面的疗效仅略优于晶体液。一些研究者发起的高质量随机对照试验表明，胶体液在短期生理指标上的适度改善并未转化为更好的以患者为中心的结局。此外，有大量证据表明，某些类型的液体可能会独立恶化以患者为中心的结局。这些包括特定患者群体中的羟乙基淀粉和白蛋白溶液。没有证据支持使用其他胶体液。大型观察性研究表明使用平衡盐溶液没有危害，这支持优先使用平衡盐溶液而非0.9%生理盐水。然而，目前尚无基于随机试验的确凿证据表明，与0.9%生理盐水相比，使用平衡盐溶液能改善临床结局。
