手术病人术中限制性输液与术后转归
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摘要
液体治疗策略一直是争论的焦点之一。数十年来对应激状态下的体液平衡观点和相应的输液管理不断发生变化,现在的输液观点多支持液体复苏,以补足术前禁饮禁食、肠道准备、失血、第三间隙效应引起的液体丢失和维持麻醉后循环稳定,避免组织灌注和氧合的不足。但研究表明某些术后并发症的发生和大量的输液有关,适度的限制液体摄入可以改善预后。以下就相关限制性输液的近年临床试验、容量的监测和存在问题等进行综述。
There is a long-standing controversy about the fluid therapy .The concepts of fluid management have been developed in the past decades. At present great volume of fluid is administered to maintain an effective circulating volume,and prevent inadequate tissue perfusion. It' shown that the administration of large-volume of fluid is associated with the development of postoperative complications,and moderate limit of liquid intake improves the outcomes in the surgery.
There is a long-standing controversy about the fluid therapy .The concepts of fluid management have been developed in the past decades. At present great volume of fluid is administered to maintain an effective circulating volume,and prevent inadequate tissue perfusion. It' shown that the administration of large-volume of fluid is associated with the development of postoperative complications,and moderate limit of liquid intake improves the outcomes in the surgery.
引文
1.Hahn,Robert GFluid Therapy Might Be More Diffecult Than You Think.Anesth Analg 2007;105:304-305
2.Rosenthal MH.Intraoperative fluid management-what and how much? Chest 1999;115:106S-112.
3.Grocott MP,Mythen MG,Gan TJ.Perioperative fluid management and clinical outcomes in adults.Anesth Analg 2005;100:1093-106
4.M.C.Bellamy.Wet,dry or something else?Br J Anaesth 2006;97:755-757
5.Moore FD.Metabolic Care of the Surgical Patient.Philadelphia:WB Saunders Co,1959.
6.Shires T,Williams J,Brown F.Acute changes in extracellular fluids associated with major surgical procedures.Ann Surg 1961;154:803-810
7.Shoemaker WC,Appel P,Bland R.Use of physiologic monitoring to predict outcome and to assist in clinical decisions in critically ill postoperative patients.Am J Surg,1983,146(1):43-50.
8.Kita T,Mammoto T,Kishi Y.Fluid management and postoperative respirative disturbances in patients with transthoracic esophagectomy for carcinoma.J Clin Anesth 2002;14:252- 256.
9.Arieff AI.Fatal postoperative pulmonary edema:Pathogenesis and literature review.Chest 1999;115:1371-1377
10.邵永胜,张应天.腹部外科重症及大手术病人围手术期的液体治疗.临床外科杂志1999,7(4)191-193
11.Holte K,Sharrock NE,Kehlet H.Pathophysiology and clinical implications of perioperative fluid excess.Br J Anaesth 2002;89:622-632
12.Sinclair S,James S,Singer M.Intraoperative intravascular volume optimisation and length of hospital stay after repair of proximal femoral fracture:randomised controlled trial.Br Med J 1997; 315:909-912
13. Polanczyk CA,Rohde LE,Goldman L,et al.Right heart catheterization and cardiac complications in patients undergoing noncardiac surgery:an observational study.JAMA 2001;286:309-314
14. Moller AM, Pedersen T, Svenden P, et al. Perioperative risk factors in elective pneumonectomy: The impact of excess fluid balance. Eur J Anaesthesiol, 2002; 19:57- 62
15. Cousins M J,Mazze R I.Anaesthesis, surgery and renal function:immediate and delayed effects.Anaesth Intensive Care,2003;1:355
16. Maxwell RA,Fabian TC,Croce MA, et al.Secondary abdominal compartment syndrome:an underappreciated manifestation of severe hemorrhagic shock.J Trauma 1999;47:995-999
17. Lang K,Boldt J,Suttner S, et al.Colloids versus crystalloids and tissue oxygen tension in patients undergoing major abdominal surgery.Anesth Analg 2001;93:405-409
18. Ng KF, Lam CC, Chan LC. In vivo effect of haemodilution with saline on coagulation: a randomized controlled trial. Br J Anaesth 2002; 88:475-480
19. Boldt J. New light on intravascular volume replacement regimens: what did we learn from the past three years? Anesth Analg 2003;97:1595-1604
20. PetrasovicovaI, Sklienka P, KolorL, et al .The clinical relevance of the fluid balance in critically ill patients. CritCare, 2000,4 (suppl): 19
21. Brady M, Kinn S,Stuart P. Preoperative fasting for adults to prevent perioperative complications. Cochrane Database Syst Rev 2003:CD004423
22. Holte K, Kehlet H. Compensatory fluid administration for preoperative dehydration—does it improve outcome?Acta Anaesthesiol Scand 2002; 46:1089-1093
23. Sanders G,Mercer SJ,Saeb-Parsey K,et al.Randomized clinical trial of intravenous fluid replacement during bowel preparation for surgery.Br J Surg 2001;88:1363-1365
24. Brandstrup B, Tonnesen H, Beier-Holgersen R, et al. Effects of intravenous fluid restriction on postoperative complications: comparison of two perioperative fluid trails. Ann Surg. 2003;238:641-648
25. Nisanevich V, Felsenstein I, Almogy G, et al. Effect of intraoperative fluid management on outcome after intraabdominal surgery. Anesthesiology 2005;103(1):25-32
26. Holte K, Klarskov B, Christensen DS, et al. Liberal versus restrictive fluid administration to improve recovery after laparoscopic cholecystectomy: a randomized, double-blind study. Ann Surg 2004;240:892-899
27. Holte K, Kristensen Billy B,Valetiner, et al.Liberal Versus Restrictive Fluid Management in Knee Arthroplasty: A Randomized, Double-Blind Study. Anesth Analg 2007;105:467-476
28. Arkilic CF,Taguchi A,Sharma N,et al.Supplemental perioperative fluid administration increases tissue oxygen pressure. Surgery 2003;133:49-55
29. Kabon,Barbara et al.Supplemental Intravenous Crystalloid Administration Dose Not Reduce the Risk of Surgical Wound Infection .Anesth Analg 2005;101:1546-1553
30. M Barak,M Rudin,O Vofsi,at el.Fluid administration during abdominal surgery influences on coagulation in the postoperative period.Curr Surg 2004;50:3
31. M Barak, Oded Jurim, Ronit Tal, Prolonged International Normalized Ratio Correlates with a Large Intravascular Fluid Balance After Major Abdominal Surgery. Anesth Analg 2006;103:448-452
32.屈伸,刘红,海克蓉.两种液体治疗方案在直、结肠手术中的临床观察.宁夏医学杂志.2007,29(11):976-978
33.Pirat A,Ozgur S,Torgay A,et al.Risk factors for postoperative respiratory complications in adult liver transplant recipients.Transplant Proc,2004,36(1):218-220
34.Snowden CP,Hughes T,Rose J,et al.Pulmonary edema in patients after liver transplantation.Liver Transpl,2000,6(4):466-470
35.R.Phillip Dellinger,Jean M.Carlet,Henry Masur.Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock.2004,30(4):536-555
36.石学银,徐振东,徐海涛等.肝移植病人液体治疗策略的回顾性研究.临床麻醉学杂志.2004,20(8):506-507
37.张燏,刘虎,徐海涛等.肝移植无肝期应用去甲肾上腺素和多巴胺对肾功能影响的比较研究.临床军医杂志.2007,35(2):195-198
38.张利萍,杨璐,侯娟等.多巴胺或多巴胺复合去甲肾上腺素对肝移植术中患者血液动力学、氧代谢及肾功能的影响.中华麻醉学杂志.2006,26(3):217-220
39.Hamilton-Davies C,Mythen M,Salmon J.Comparison of commonly used clinical indicators of hypovolaemia with gastrointestinal tonometry.Intensive Care Med,1997,23;276
40.Mckinley BA,Parmley CL,ButlerBD,et al.Skeletal muscle PO2,PCO2and pH in hemorrhage,shock,and resuscitation in dogs.J Trauma,1998,44(1):119-127
41.Crookes Crookes BA,Cohn SM,Burton EA,et al.Noninvasivemuscle oxygenation to guide fluid resuscitation after traumatic shock.Surgery,2004,135(6):662-670
42. Conway DH, Mayall R, Abdul-Latif MS, et al. Randomised controlled trial investigating the influence of intravenous fluid titration using oesophageal Doppler monitoring during bowel surgery. Anaesthesia 2002;57:845-849
43. Wakeling HG, McFall MR, Jenkins CS, et al. Intraoperative oesophageal Doppler guided fluid management shortens postoperative hospital stay after major bowel surgery. Br J Anaesth 2005;95:634-642
44. Noblett SE, Snowden CP, Shenton BK,et al. Randomized clinical trial assessing the effect of Doppler-optimized fluid management on outcome after elective colorectal resection. Br J Surg2006,93:1069-1076
1.Holte K,Kehlet H.Fluid Therapy and Surgical Outcomes in Elective Surgery:A Need for Reassessment in Fast-Track Surgery.J Am Coll Surg,2006,202:971-989
2.Pirat A,Ozgur S,Torgay A,et al.Risk factors for postoperative respiratory complications in adult liver transplant recipients.Transplant Proc,2004,36(1):218-220
3.McGilvray ID,Greig PD.Critical care of the liver transplant patient:an update.Curr Opin Crit Care,2002,8(2):178-182.
4.Golfieril R,GiampalmalE.Pulmonary complications of liver transplantation:radiological appearance and statistical evaluation of risk factors in 300 cases.Eur.Radiol,2000,10:1169-1183
5.黑子清,主编.肝脏移植麻醉学.广州:中山大学出版社,2006,
6.R.Dellinger,J.Cadet,H Masur.Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock.2004,30(4):536-555
7.Chen H,Merchant NB,Didolkar MS.Hepatic resection using intermittent vascular inflow occlusion and low central venous pressure anesthesia improves morbidity and mortality.J Gastrointest Surg,2000,4(2):162-167
8.Holte K,Sharrock NE,Kehlet H.Pathophysiology and clinical implications of perioperative fluid excess.Br J Anaesth 2002;89:622-632
9.张利萍,杨璐,侯娟等.多巴胺或多巴胺复合去甲肾上腺素对肝移植术中患者血液动力学、氧代谢及肾功能的影响.中华麻醉学杂志.2006,26(3):217-220
10.石学银,徐振东,徐海涛等.肝移植病人液体治疗策略的回顾性研究.临床麻醉学杂志.2004,20(8):506-507
11.Nakata Y,SatoM,Watanabe Y,et al.Intraoperative Fluid Requirements During Porcine Liver Transplantation.Transplant Proc,2000,32(7):2338-2339
2.Rosenthal MH.Intraoperative fluid management-what and how much? Chest 1999;115:106S-112.
3.Grocott MP,Mythen MG,Gan TJ.Perioperative fluid management and clinical outcomes in adults.Anesth Analg 2005;100:1093-106
4.M.C.Bellamy.Wet,dry or something else?Br J Anaesth 2006;97:755-757
5.Moore FD.Metabolic Care of the Surgical Patient.Philadelphia:WB Saunders Co,1959.
6.Shires T,Williams J,Brown F.Acute changes in extracellular fluids associated with major surgical procedures.Ann Surg 1961;154:803-810
7.Shoemaker WC,Appel P,Bland R.Use of physiologic monitoring to predict outcome and to assist in clinical decisions in critically ill postoperative patients.Am J Surg,1983,146(1):43-50.
8.Kita T,Mammoto T,Kishi Y.Fluid management and postoperative respirative disturbances in patients with transthoracic esophagectomy for carcinoma.J Clin Anesth 2002;14:252- 256.
9.Arieff AI.Fatal postoperative pulmonary edema:Pathogenesis and literature review.Chest 1999;115:1371-1377
10.邵永胜,张应天.腹部外科重症及大手术病人围手术期的液体治疗.临床外科杂志1999,7(4)191-193
11.Holte K,Sharrock NE,Kehlet H.Pathophysiology and clinical implications of perioperative fluid excess.Br J Anaesth 2002;89:622-632
12.Sinclair S,James S,Singer M.Intraoperative intravascular volume optimisation and length of hospital stay after repair of proximal femoral fracture:randomised controlled trial.Br Med J 1997; 315:909-912
13. Polanczyk CA,Rohde LE,Goldman L,et al.Right heart catheterization and cardiac complications in patients undergoing noncardiac surgery:an observational study.JAMA 2001;286:309-314
14. Moller AM, Pedersen T, Svenden P, et al. Perioperative risk factors in elective pneumonectomy: The impact of excess fluid balance. Eur J Anaesthesiol, 2002; 19:57- 62
15. Cousins M J,Mazze R I.Anaesthesis, surgery and renal function:immediate and delayed effects.Anaesth Intensive Care,2003;1:355
16. Maxwell RA,Fabian TC,Croce MA, et al.Secondary abdominal compartment syndrome:an underappreciated manifestation of severe hemorrhagic shock.J Trauma 1999;47:995-999
17. Lang K,Boldt J,Suttner S, et al.Colloids versus crystalloids and tissue oxygen tension in patients undergoing major abdominal surgery.Anesth Analg 2001;93:405-409
18. Ng KF, Lam CC, Chan LC. In vivo effect of haemodilution with saline on coagulation: a randomized controlled trial. Br J Anaesth 2002; 88:475-480
19. Boldt J. New light on intravascular volume replacement regimens: what did we learn from the past three years? Anesth Analg 2003;97:1595-1604
20. PetrasovicovaI, Sklienka P, KolorL, et al .The clinical relevance of the fluid balance in critically ill patients. CritCare, 2000,4 (suppl): 19
21. Brady M, Kinn S,Stuart P. Preoperative fasting for adults to prevent perioperative complications. Cochrane Database Syst Rev 2003:CD004423
22. Holte K, Kehlet H. Compensatory fluid administration for preoperative dehydration—does it improve outcome?Acta Anaesthesiol Scand 2002; 46:1089-1093
23. Sanders G,Mercer SJ,Saeb-Parsey K,et al.Randomized clinical trial of intravenous fluid replacement during bowel preparation for surgery.Br J Surg 2001;88:1363-1365
24. Brandstrup B, Tonnesen H, Beier-Holgersen R, et al. Effects of intravenous fluid restriction on postoperative complications: comparison of two perioperative fluid trails. Ann Surg. 2003;238:641-648
25. Nisanevich V, Felsenstein I, Almogy G, et al. Effect of intraoperative fluid management on outcome after intraabdominal surgery. Anesthesiology 2005;103(1):25-32
26. Holte K, Klarskov B, Christensen DS, et al. Liberal versus restrictive fluid administration to improve recovery after laparoscopic cholecystectomy: a randomized, double-blind study. Ann Surg 2004;240:892-899
27. Holte K, Kristensen Billy B,Valetiner, et al.Liberal Versus Restrictive Fluid Management in Knee Arthroplasty: A Randomized, Double-Blind Study. Anesth Analg 2007;105:467-476
28. Arkilic CF,Taguchi A,Sharma N,et al.Supplemental perioperative fluid administration increases tissue oxygen pressure. Surgery 2003;133:49-55
29. Kabon,Barbara et al.Supplemental Intravenous Crystalloid Administration Dose Not Reduce the Risk of Surgical Wound Infection .Anesth Analg 2005;101:1546-1553
30. M Barak,M Rudin,O Vofsi,at el.Fluid administration during abdominal surgery influences on coagulation in the postoperative period.Curr Surg 2004;50:3
31. M Barak, Oded Jurim, Ronit Tal, Prolonged International Normalized Ratio Correlates with a Large Intravascular Fluid Balance After Major Abdominal Surgery. Anesth Analg 2006;103:448-452
32.屈伸,刘红,海克蓉.两种液体治疗方案在直、结肠手术中的临床观察.宁夏医学杂志.2007,29(11):976-978
33.Pirat A,Ozgur S,Torgay A,et al.Risk factors for postoperative respiratory complications in adult liver transplant recipients.Transplant Proc,2004,36(1):218-220
34.Snowden CP,Hughes T,Rose J,et al.Pulmonary edema in patients after liver transplantation.Liver Transpl,2000,6(4):466-470
35.R.Phillip Dellinger,Jean M.Carlet,Henry Masur.Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock.2004,30(4):536-555
36.石学银,徐振东,徐海涛等.肝移植病人液体治疗策略的回顾性研究.临床麻醉学杂志.2004,20(8):506-507
37.张燏,刘虎,徐海涛等.肝移植无肝期应用去甲肾上腺素和多巴胺对肾功能影响的比较研究.临床军医杂志.2007,35(2):195-198
38.张利萍,杨璐,侯娟等.多巴胺或多巴胺复合去甲肾上腺素对肝移植术中患者血液动力学、氧代谢及肾功能的影响.中华麻醉学杂志.2006,26(3):217-220
39.Hamilton-Davies C,Mythen M,Salmon J.Comparison of commonly used clinical indicators of hypovolaemia with gastrointestinal tonometry.Intensive Care Med,1997,23;276
40.Mckinley BA,Parmley CL,ButlerBD,et al.Skeletal muscle PO2,PCO2and pH in hemorrhage,shock,and resuscitation in dogs.J Trauma,1998,44(1):119-127
41.Crookes Crookes BA,Cohn SM,Burton EA,et al.Noninvasivemuscle oxygenation to guide fluid resuscitation after traumatic shock.Surgery,2004,135(6):662-670
42. Conway DH, Mayall R, Abdul-Latif MS, et al. Randomised controlled trial investigating the influence of intravenous fluid titration using oesophageal Doppler monitoring during bowel surgery. Anaesthesia 2002;57:845-849
43. Wakeling HG, McFall MR, Jenkins CS, et al. Intraoperative oesophageal Doppler guided fluid management shortens postoperative hospital stay after major bowel surgery. Br J Anaesth 2005;95:634-642
44. Noblett SE, Snowden CP, Shenton BK,et al. Randomized clinical trial assessing the effect of Doppler-optimized fluid management on outcome after elective colorectal resection. Br J Surg2006,93:1069-1076
1.Holte K,Kehlet H.Fluid Therapy and Surgical Outcomes in Elective Surgery:A Need for Reassessment in Fast-Track Surgery.J Am Coll Surg,2006,202:971-989
2.Pirat A,Ozgur S,Torgay A,et al.Risk factors for postoperative respiratory complications in adult liver transplant recipients.Transplant Proc,2004,36(1):218-220
3.McGilvray ID,Greig PD.Critical care of the liver transplant patient:an update.Curr Opin Crit Care,2002,8(2):178-182.
4.Golfieril R,GiampalmalE.Pulmonary complications of liver transplantation:radiological appearance and statistical evaluation of risk factors in 300 cases.Eur.Radiol,2000,10:1169-1183
5.黑子清,主编.肝脏移植麻醉学.广州:中山大学出版社,2006,
6.R.Dellinger,J.Cadet,H Masur.Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock.2004,30(4):536-555
7.Chen H,Merchant NB,Didolkar MS.Hepatic resection using intermittent vascular inflow occlusion and low central venous pressure anesthesia improves morbidity and mortality.J Gastrointest Surg,2000,4(2):162-167
8.Holte K,Sharrock NE,Kehlet H.Pathophysiology and clinical implications of perioperative fluid excess.Br J Anaesth 2002;89:622-632
9.张利萍,杨璐,侯娟等.多巴胺或多巴胺复合去甲肾上腺素对肝移植术中患者血液动力学、氧代谢及肾功能的影响.中华麻醉学杂志.2006,26(3):217-220
10.石学银,徐振东,徐海涛等.肝移植病人液体治疗策略的回顾性研究.临床麻醉学杂志.2004,20(8):506-507
11.Nakata Y,SatoM,Watanabe Y,et al.Intraoperative Fluid Requirements During Porcine Liver Transplantation.Transplant Proc,2000,32(7):2338-2339