急重症-烧伤休克病理改变与液体复苏.pptx

烧伤及烧伤性休克的液体治疗烧伤及烧伤休克概述什么是烧伤？血容量减少毛细血管通透性改变血浆渗透压降低加重血浆成分外渗钠离子与水分同步丢失创面水分蒸发导致血容量减少毛细血管通透性改变血浆渗透压降低加重血浆成分外渗钠离子与水分同步丢失创面水分蒸发导致血容量减少热力损伤烧伤及烧伤休克概述液体的两种观点retrospectivestudy延迟复苏对烧伤患者组织器官损伤严重目标导向的容量管理是发展趋势液体治疗的关键是目标导向，目标导向的前提是监测方法无创循环检测指标复苏目标(EGDT)EGDT在烧伤休克的应用1EGDT在烧伤休克的应用1EGDT在烧伤休克的应用1快速充分的液体复苏快速充分的液体复苏复苏原则烧伤面积超过20％～25％总体表面积(TBsA)者多伴发毛细血管通透性增加和血容量不足其改变以伤后第一个24h尤为明显恰当液体复苏的目的是用最少的液体量和最小的生理代价支持器官灌注液体复苏不足会导致血流灌注减少，出现急性肾功能衰竭(ARF)，甚至死亡烧伤及烧伤休克概述伤后早期有血液浓缩的问题，不宜输血；开始复苏时宜尽快输入电解质、水分及血浆等胶体。大面积严重烧伤需输血，伤后6-8h血浓缩减轻后再输全血。病原体传播：HCV、HBV、HIV白蛋白1白蛋白1胶体液复苏胶体液复苏胶体液复苏胶体与晶体Albuminorplasmaproteinfraction-24trialsreporteddataonmortality,includingatotalof9920patients.Thepooledriskratio(RR)was1.01(95%CI0.93to1.10).Excludedthetrialwithpoor-qualityallocationconcealment,pooledRRwas1.00(95%CI0.92to1.09).Hydroxyethylstarch-25trialscomparedhydroxyethylstarchwithcrystalloidsandincluded9147patients.ThepooledRRwas1.10(95%CI1.02to1.19).Modifiedgelatin-11trialscomparedmodifiedgelatinwithcrystalloidandincluded506patients.ThepooledRRwas0.91(95%CI0.49to1.72).(WhenthetrialsbyBoldtetalwereremovedfromthethreeprecedinganalyses,theresultswereunchanged.)Dextran-ninetrialscompareddextranwithacrystalloidandincluded834patients.ThepooledRRwas1.24(95%CI0.94to1.65).ColloidsinhypertoniccrystalloidcomparedtoisotoniccrystalloidNinetrialscompareddextraninhypertoniccrystalloidwithisotoniccrystalloid,including1985randomisedparticipants.PooledRRformortalitywas0.91(95%CI0.71to1.06).conclusionsThereisnoevidencethatresuscitationwithcolloidsreducestheriskofdeath,comparedtoresuscitationwithcrystalloids,inpatientswithtrauma,burnsorfollowingsurgery.Furthermore,theuseofhydroxyethylstarchmightincreasemortality.Ascolloidsarenotassociatedwithanimprovementinsurvivalandareconsiderablymoreexpensivethancrystalloids.HSL复苏HESshouldnotbeusedforfluidreplacementincriticallyillpatientsorthosewithsepsisorburninjuries,ruledtheEuropeanMedicinesAgency(EMA)on11Octoberafterreviewingevidenceshowingincreasedriskofdeathorkidneyinjury.Potentialrisksshouldbeminimis