AP-HP, Service de Médecine Intensive-Réanimation, Hôpital de Bicêtre, DMU 4 CORREVE, Inserm UMR S_999, FHU SEPSIS, CARMAS, Université Paris-Saclay, 78 Rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France.
Crit Care. 2023 Mar 24;27(1):123. doi: 10.1186/s13054-023-04363-3.
During septic shock, fluid therapy is aimed at increasing cardiac output and improving tissue oxygenation, but it poses two problems: it has inconsistent and transient efficacy, and it has many well-documented deleterious effects. We suggest that there is a place for its personalization according to the patient characteristics and the clinical situation, at all stages of circulatory failure. Regarding the choice of fluid for volume expansion, isotonic saline induces hyperchloremic acidosis, but only for very large volumes administered. We suggest that balanced solutions should be reserved for patients who have already received large volumes and in whom the chloremia is rising. The initial volume expansion, intended to compensate for the constant hypovolaemia in the initial phase of septic shock, cannot be adapted to the patient's weight only, as suggested by the Surviving Sepsis Campaign, but should also consider potential absolute hypovolemia induced by fluid losses. After the initial fluid infusion, preload responsiveness may rapidly disappear, and it should be assessed. The choice between tests used for this purpose depends on the presence or absence of mechanical ventilation, the monitoring in place and the risk of fluid accumulation. In non-intubated patients, the passive leg raising test and the mini-fluid challenge are suitable. In patients without cardiac output monitoring, tests like the tidal volume challenge, the passive leg raising test and the mini-fluid challenge can be used as they can be performed by measuring changes in pulse pressure variation, assessed through an arterial line. The mini-fluid challenge should not be repeated in patients who already received large volumes of fluids. The variables to assess fluid accumulation depend on the clinical condition. In acute respiratory distress syndrome, pulmonary arterial occlusion pressure, extravascular lung water and pulmonary vascular permeability index assess the risk of worsening alveolar oedema better than arterial oxygenation. In case of abdominal problems, the intra-abdominal pressure should be taken into account. Finally, fluid depletion in the de-escalation phase is considered in patients with significant fluid accumulation. Fluid removal can be guided by preload responsiveness testing, since haemodynamic deterioration is likely to occur in patients with a preload dependent state.
在脓毒性休克中，液体治疗的目的是增加心输出量和改善组织氧合，但它存在两个问题：疗效不一致且短暂，并且有许多已充分记录的有害影响。我们建议根据患者的特征和临床情况，在循环衰竭的所有阶段对其进行个体化治疗。关于容量扩张的液体选择，等渗盐水会引起高氯性酸中毒，但仅在输注大量液体时才会发生。我们建议，对于已经接受大量液体输注且氯升高的患者，应保留平衡溶液。最初的容量扩张旨在补偿脓毒性休克初始阶段的持续低血容量，但不能仅根据拯救脓毒症运动建议的患者体重来调整，还应考虑因液体丢失引起的潜在绝对低血容量。初始液体输注后，前负荷反应性可能会迅速消失，应进行评估。用于评估前负荷反应性的测试选择取决于是否存在机械通气、监测情况和液体蓄积风险。对于非插管患者，被动抬腿试验和小容量液体冲击试验是合适的。对于没有心输出量监测的患者，可以使用潮气量挑战、被动抬腿试验和小容量液体冲击试验等测试，因为它们可以通过测量脉搏压变化来进行，通过动脉线评估。已经接受大量液体输注的患者不应重复进行小容量液体冲击试验。评估液体蓄积的变量取决于临床情况。在急性呼吸窘迫综合征中，肺动脉闭塞压、肺血管外肺水和肺血管通透性指数比动脉氧合更好地评估肺泡水肿恶化的风险。在存在腹部问题的情况下，应考虑腹内压。最后，在有明显液体蓄积的患者中，在降级阶段考虑液体耗竭。液体清除可以通过前负荷反应性测试来指导，因为血流动力学恶化可能发生在依赖前负荷的患者中。
