Cartotto Robert, Greenhalgh David G, Cancio C
From the *Department of Surgery, Ross Tilley Burn Centre, University of Toronto, Canada; †Shriners Hospitals for Children Northern California and University of California, Davis Medical Center, Sacramento; and ‡U.S. Army Institute of Surgical Research, Fort Sam Houston, Texas.
J Burn Care Res. 2017 May/Jun;38(3):e596-e604. doi: 10.1097/BCR.0000000000000541.
Recognition of fluid creep has driven a large amount of the scientific investigation in the area of acute fluid resuscitation for burn patients. The role of colloids in ameliorating fluid creep is controversial, despite the fact that a fluid-sparing effect of colloids has been recognized for some time. All but one of the available prospective studies using colloids are more than a decade old, and a modern randomized controlled trial (RCT) comparing crystalloids to colloids is long overdue. While urinary output continues to be the main endpoint for fluid titration, there has been a moderate amount of interest in the use of transpulmonary thermodilution to guide fluid resuscitation. The available studies have found that transpulmonary thermodilution has had an inconsistent effect on limiting fluid resuscitation volumes and improving clinical outcomes. Computerized Decision Support Systems show great promise in optimizing fluid titration and reducing fluid resuscitation volumes, and an RCT comparing Computerized Decision Support Systems with conventional titration approaches will be the important next step. Use of high-dose vitamin C (ascorbic acid) has become a popular approach to limit fluid resuscitation volumes and edema formation, but it has been investigated in only two clinical studies: one a pseudo-randomized prospective study and the other a retrospective study. Improvements in clinical outcome have not been convincingly demonstrated, and concerns persist surrounding the possibility of induction of an osmotic diuresis, leading to intravascular volume depletion. An RCT is urgently required to evaluate high-dose vitamin C as an adjunct to crystalloid resuscitation compared with the use of crystalloids alone.
对液体蠕变的认识推动了烧伤患者急性液体复苏领域的大量科学研究。尽管胶体的液体节省作用已被认识一段时间，但胶体在改善液体蠕变方面的作用仍存在争议。除一项研究外，所有使用胶体的前瞻性研究都已有十多年历史，早就该进行一项比较晶体液和胶体液的现代随机对照试验（RCT）了。虽然尿量仍是液体滴定的主要终点，但人们对使用经肺热稀释法指导液体复苏也有一定兴趣。现有研究发现，经肺热稀释法在限制液体复苏量和改善临床结局方面的效果并不一致。计算机化决策支持系统在优化液体滴定和减少液体复苏量方面显示出巨大潜力，比较计算机化决策支持系统与传统滴定方法的RCT将是下一步的重要举措。使用高剂量维生素C（抗坏血酸）已成为限制液体复苏量和水肿形成的常用方法，但仅在两项临床研究中进行了调查：一项是伪随机前瞻性研究，另一项是回顾性研究。尚未令人信服地证明临床结局有改善，而且对于诱导渗透性利尿导致血管内容量耗竭的可能性仍存在担忧。迫切需要进行一项RCT，以评估与单独使用晶体液复苏相比，高剂量维生素C作为晶体液复苏辅助手段的效果。
