Chang Ronald, Holcomb John B
*Center for Translational Injury Research, University of Texas Health Science Center, Houston, Texas †Department of Surgery, University of Texas Health Science Center, Houston, Texas.
Shock. 2016 Jul;46(1):17-26. doi: 10.1097/SHK.0000000000000577.
Sepsis results in disruption of the endothelial glycocalyx layer and damage to the microvasculature, resulting in interstitial accumulation of fluid and subsequently edema. Fluid resuscitation is a mainstay in the initial treatment of sepsis, but the choice of fluid is unclear. The ideal resuscitative fluid is one that restores intravascular volume while minimizing edema; unfortunately, edema and edema-related complications are common consequences of current resuscitation strategies. Crystalloids are recommended as first-line therapy, but the type of crystalloid is not specified. There is increasing evidence that normal saline is associated with increased mortality and kidney injury; balanced crystalloids may be a safer alternative. Albumin is similar to crystalloids in terms of outcomes in the septic population but is costlier. Hydroxyethyl starches appear to increase mortality and kidney injury in the critically ill and are no longer indicated in these patients. In the trauma population, the shift to plasma-based resuscitation with decreased use of crystalloid and colloid in the treatment of hemorrhagic shock has led to decreased inflammatory and edema-mediated complications. Studies are needed to determine if these benefits also occur with a similar resuscitation strategy in the setting of sepsis.
脓毒症会导致内皮糖萼层破坏和微血管损伤，进而引起液体在间质积聚并随后出现水肿。液体复苏是脓毒症初始治疗的主要手段，但液体的选择尚不明确。理想的复苏液体应是能恢复血管内容量同时使水肿最小化的液体；不幸的是，水肿及与水肿相关的并发症是当前复苏策略的常见后果。晶体液被推荐作为一线治疗，但未明确晶体液的类型。越来越多的证据表明，生理盐水与死亡率增加和肾损伤有关；平衡晶体液可能是更安全的选择。白蛋白在脓毒症患者中的治疗效果与晶体液相似，但成本更高。羟乙基淀粉似乎会增加危重症患者的死亡率和肾损伤，在这些患者中不再推荐使用。在创伤患者中，在失血性休克治疗中转向以血浆为主的复苏，减少晶体液和胶体液的使用，已导致炎症和水肿介导的并发症减少。需要开展研究来确定在脓毒症情况下采用类似的复苏策略是否也会产生这些益处。
