Department of Critical Care Medicine and Anaesthesia, The Royal Wolverhampton NHS Trust, New Cross Hospital, Wolverhampton, UK.
Discipline of Anesthesiology and Critical Care, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa.
Curr Opin Crit Care. 2024 Dec 1;30(6):664-671. doi: 10.1097/MCC.0000000000001201. Epub 2024 Sep 3.
This review provides insight into recent clinical studies involving septic peri-operative patients and highlights gaps in understanding fluid management. The aim is to enhance the understanding of safe fluid resuscitation to optimize peri-operative outcomes and reduce complications.
Recent research shows adverse surgical and clinical outcomes with both under- and over-hydration of peri-operative patients. The kinetic of intravenous fluids varies significantly during surgery, general anaesthesia, and sepsis with damage to endothelial glycocalyx (EG), which increases vascular permeability and interstitial oedema. Among clinical anaesthesia, neuraxial anaesthesia and sevoflurane have less effect on EG. Hypervolemia and the speed and volume of fluid infusion are also linked to EG shedding. Despite improvement in the antisepsis strategies, peri-operative sepsis is not uncommon. Fluid resuscitation is the cornerstone of sepsis management. However, overzealous fluid resuscitation is associated with increased mortality in patients with sepsis and septic shock. Personalized fluid resuscitation based on a careful assessment of intravascular volume status, dynamic haemodynamic variables and fluid tolerance appears to be a safe approach. Balanced solutions (BS) are preferred over 0.9% saline in patients with sepsis and septic shock due to a potential reduction in mortality, when exclusive BS are used and/or large volume of fluids are required for fluid resuscitation. Peri-operative goal-directed fluid therapy (GDFT) using dynamic haemodynamic variables remains an area of interest in reducing postoperative complications and can be considered for sepsis management (Supplementary Digital Content).
Optimization of peri-operative fluid management is crucial for improving surgical outcomes and reducing postoperative complications in patients with sepsis. Individualized and GDFT using BS is the preferred approach for fluid resuscitation in septic peri-operative patients. Future research should evaluate the interaction between clinical anaesthesia and EG, its implications on fluid resuscitation, and the impact of GDFT in septic peri-operative patients.
本综述提供了对最近涉及脓毒症围手术期患者的临床研究的深入了解，并强调了对液体管理认识不足的问题。目的是增强对安全液体复苏的理解，以优化围手术期结果并减少并发症。
最近的研究表明，围手术期患者液体过少和过多都会导致不良的手术和临床结果。在手术、全身麻醉和脓毒症期间，静脉输液的动力学变化很大，内皮糖萼（EG）受损，导致血管通透性增加和间质水肿。在临床麻醉中，神经轴麻醉和七氟醚对 EG 的影响较小。血容量过多以及输液速度和容量也与 EG 脱落有关。尽管在抗感染策略方面有所改进，但围手术期脓毒症仍很常见。液体复苏是脓毒症管理的基石。然而，在脓毒症和脓毒性休克患者中，过度积极的液体复苏与死亡率增加有关。基于对血管内容量状态、动态血流动力学变量和液体耐受性的仔细评估，个性化液体复苏似乎是一种安全的方法。在脓毒症和脓毒性休克患者中，由于潜在的死亡率降低，平衡溶液（BS）优于 0.9%生理盐水，当单独使用 BS 或需要大量液体进行液体复苏时。使用动态血流动力学变量的围手术期目标导向液体治疗（GDFT）仍然是减少术后并发症的研究热点，可考虑用于脓毒症管理（补充数字内容）。
优化围手术期液体管理对于改善脓毒症患者的手术结果和减少术后并发症至关重要。个体化和使用 BS 的 GDFT 是脓毒症围手术期患者液体复苏的首选方法。未来的研究应评估临床麻醉与 EG 之间的相互作用及其对液体复苏的影响，以及 GDFT 在脓毒症围手术期患者中的影响。
