Fluid ManagementFluid Management

灌注的生理学：压力和流量

Adequate perfusion requires adequate arterial pressure and cardiac output (CO)

必须有适当的动脉压和心输出量（CO）才能达到适当的灌注

Cardiac Output (CO) = Stroke Volume x Heart Rate

心输出量（CO）=每搏输出量×心率

如需了解关于管理低血压的更多信息，请单击此处。

管理灌注的流量部分

关键在于使患者保持在最佳容量范围内。使用基于流量的动态参数来指导液体管理，有助于使患者保持在最佳容量范围内。1

容量不足与下列各项相关：

  • 胃肠道功能障碍（术后肠梗阻、术后恶心呕吐(PONV)、上消化道出血、吻合口瘘）2
  • 感染性并发症（组织灌注不足）2,3
  • 急性肾功能不全或肾衰竭4
Using dynamic and flow-based parameters to guide fluid administration helps maintain patients in the optimal volume range.

容量过度与下列各项相关：

  • 肺水肿5
  • 胃肠道功能障碍（腹腔室隔综合征、肠梗阻、吻合口瘘）17,18,19
  • 凝血功能障碍5
个性化容量管理
Preload: the tension of myocardial fibers at the end of diastole, as a result of volume in the ventricle
Stroke Volume (SV): volume of blood pumped from the left ventricle per heartbeat

前负荷：舒张末期心肌纤维的张力，是心室容积的结果

每搏输出量（SV）：每次心搏时从左心室泵出的血量

管理灌注时，可以使用患者自己的Frank-Starling曲线（每搏量输出量（SV）vs.前负荷的曲线）来优化每搏输出量。

位于Frank-Starling曲线肩部时，每搏输出量是最佳的（参见下图）。

When managing perfusion, stroke volume can be optimized using the patient’s own Frank-Starling curve

通过采用下列方式，测量对前负荷变化的反应（∆SV），可以确定患者在其Frank-Starling曲线上的位置：

液体推注挑战

Bolus fluid challenge

被动抬腿实验（PLR）

Passive leg raise (PLR)

就确定液体反应性而言，基于流量的动态参数提供的信息多于常规参数，并且可能有助于避免输液过量或不足。7

临床研究表明，基于常规参数的常规容量管理方法存在误导性且不敏感。6

每搏输出量（SV）和每搏量变异度（SVV）等高级血流动力学参数是优化液体管理的关键。6

已证明SVV是管理灌注时对前负荷反应具有高度敏感性和特异性的指标。SVV是一项动态参数，已证明可作为机械通气引起的负载条件下液体反应性的准确预测指标。6,8,20

研究证明动态参数和基于流量的参数价值

如需了解关于使用高级参数管理液体的更多信息，请联系我们。

Start here start now
使用围手术期目标导向治疗（PGDT）减少变异性

术后并发症会对人们的生活造成影响。9

Major complications occur in approximately 16% of surgeries.

The occurrence of even a single post-surgical complication within 30 days reduced median patient survival by 69%

Hemodynamic optimization through PGDT reduces complications like acute kidney injury and surgical site injury

约16%的手术会出现重大并发症。9

在不考虑患者术前风险的情况下，即使在30天内发生单一术后并发症，患者的中位生存率也会降低69%。10

已证明通过PGDT优化血流动力学可以减少急性肾损伤（AKI）和手术部位感染（SSI）等并发症，并减少中高风险手术患者的住院时长和相关费用。11,12

通过PGDT优化血流动力学可以：

Reduce post-surgical complications by an average of 32%

Reduce average length of stay: 1+ days

Approximate extra cost of treating one post-operative complication: $18,000-$20,000

术后并发症平均减少32%13

缩短平均住院时长：1天以上13,14

治疗一种术后并发症的额外费用约为：$18,0000 - $20,00015

PGDT是使用基于流量的动态血流动力学参数的治疗方案，目的是做出适当的容量管理决策。可以在单一手术操作中进行PGDT，也可以将其作为更大项目（例如：增强术后恢复途径）的一部分。

50多项研究证明了PGDT的使用

50多项随机对照试验和14多项荟萃分析已证明血流动力学优化的临床获益大于标准容量管理。

研究

证明围手术期目标导向治疗获益的随机对照试验

52项阳性随机对照试验中入组3000多名患者。

PAC, n = 8
(1175 名患者)		 多普勒, n = 12
(1145 名患者)		 脉搏曲线, n=29
(2621 名患者)		 A line, n = 1
(33 名患者)		 CVC, n = 2
(214 名患者)
标题、作者和年份n优化的参数外科手术工具主要获益
Prospective trial of supranormal values of survivors as therapeutic goals in high-risk patients. Shoemaker 1988 310 DO2 普外 PAC-1 发病率 死亡率（21 vs 34%） 节省成本
Preoperative optimization of cardiovascular hemodynamics improves outcomes in peripheral vascular surgery. Berlauk 1991 89 CI, PCWP, SVR 血管 PAC-2 发病率
Prospective trial of supranormal values as goals of resuscitation in severe trauma. Fleming 1992 67 DO2 创伤 PAC-3 发病率
A randomized clinical trial of the effect of deliberate perioperative increase of oxygen delivery on mortality in high-risk patients. Boyd 1993 107 DO2 普外 PAC-4 发病率 死亡率（6 vs 22%）
Perioperative plasma volume expansion reduces the incidence of gut mucosal hypoperfusion during cardiac surgery. Mythen 1995 60 SV 心脏 多普勒-1 发病率 医院住院时长
Intraoperative intravascular volume optimisation and length of hospital stay after repair of proximal femoral fracture: randomised controlled trial. Sinclair 1997 40 SV 髋关节 多普勒-2 医院住院时长
Response of patients with cirrhosis who have undergone partial hepatectomy to treatment aimed at achieving supranormal oxygen delivery and consumption. Ueno 1998 34 DO2 肝切除 PAC-5 发病率
Reducing the risk of major elective surgery: randomised controlled trial of preoperative optimization of oxygen delivery. Wilson 1999 138 DO2 普外和血管 PAC-6 发病率 医院住院时长 节省成本
A prospective, randomized study of goal-oriented hemodynamic therapy in cardiac surgical patients. Polonen 2000 393 SvO2 心脏 PAC-7 发病率 医院住院时长
Effects of maximizing oxygen delivery on morbidity and mortality in high-risk surgical patients. Lobo 2000 37 DO2 General PAC-8 发病率 死亡率（16 vs 50%）
Randomized controlled trial to investigate influence of the fluid challenge on duration of hospital stay and perioperative morbidity in patients with hip fractures. Venn 2002 59 SV 髋关节 多普勒-3 发病率
Goal-directed Intraoperative fluid administration reduces length of hospital stay after major surgery. Gan 2002 100 SV 普外 多普勒-4 发病率 医院住院时长
Randomised controlled trial investigating the influence of intravenous fluid titration using oesophageal Doppler monitoring during bowel surgery. Conway 2002 57 SV 肠道 多普勒-5 发病率
Randomised controlled trial assessing the impact of a nurse delivered, flow monitored protocol for optimisation of circulatory status after cardiac surgery. McKendry 2004 174 SV 心脏 多普勒-6 医院住院时长
Intraoperative oesophageal Doppler guided fluid management shortens postoperative hospital stay after major bowel surgery. Wakeling 2005 128 SV 肠道 多普勒-7 发病率 医院住院时长
Early goal-directed therapy after major surgery reduces complications and duration of hospital stay. A randomised, controlled trial. Pearse 2005 122 DO2 普外 LidCO-1 发病率 医院住院时长
Randomized clinical trial assessing the effect of Doppler- optimized fluid management on outcome after elective colorectal resection. Noblett 2006 108 SV 肠道 多普勒-8 发病率 医院住院时长
Esophageal Doppler-guided fluid management decreases blood lactate levels in multiple-trauma patients: a randomized controlled trial. Chytra 2007 162 SV 创伤 多普勒-9 发病率 医院住院时长
Goal-directed fluid management based on pulse pressure variation monitoring during high-risk surgery: a pilot randomized controlled trial. Lopes 2007 33 PPV 普外 A line-1 发病率 医院住院时长
Goal-directed intraoperative therapy reduces morbidity and length of hospital stay in high-risk surgical patients. Donati 2007 135 ERO2 普外和血管 CVC-1 发病率 医院住院时长
Goal-directed intraoperative therapy based on Autocalibrated arterial pressure waveform analysis reduces hospital stay in high-risk surgical patients: a randomized, controlled trial. Mayer 2009 60 SVV, SVI, CI 腹部 FloTrac传感器-1 发病率 医院住院时长
Intraoperative fluid optimization using stroke volume variation in high risk surgical patients: results of prospective randomized study. Benes 2010 120 SVV, CI 腹部和血管 FloTrac传感器-2 发病率
Haemodynamic optimisation improves tissue microvascular flow and oxygenation after major surgery: a randomised controlled trial. Jhanji 2010 135 SV, DO2 腹部 LidCO-2 发病率
Goal-directed haemodynamic therapy during elective total hip arthroplasty under regional anaesthesia. Cecconi 2011 40 DO2 髋关节 FloTrac传感器-3 发病率
A double-blind randomized controlled clinical trial to assess the effect of doppler optimized intraoperative fluid management on outcome following radical cystectomy. Pillai 2011 66 SV 膀胱切除术 多普勒-10 发病率
Haemodynamic optimisation in lower limb arterial surgery: room for improvement? Bisgaard 2012 40 SV, DO2 血管 LidCO-3 发病率
Outcome impact of goal directed fluid therapy during high risk abdominal surgery in low to moderate risk patients: a randomized controlled trial. Ramsingh 2012 38 SVV 腹部 FloTrac传感器-4 发病率 医院住院时长
Goal-directed intraoperative fluid therapy guided by stroke volume and its variation in high-risk surgical patients: a prospective randomized multicentre study. Scheeren 2012 40 SVV, SV 腹部 FloTrac传感器-5 发病率
Intraoperative fluid management in open gastrointestinal surgery: goal-directed versus restrictive. Zhang 2013 80 SVV, CI 胸部 FloTrac传感器-6 发病率
Individually optimized hemodynamic therapy reduces complications and length of stay in the Intensive Care Unit. Goepfert 2013 100 SVV, GEDI, CI, EVLW 心脏 PiCCO-1 发病率
Perioperative goal-directed hemodynamic therapy based on radial arterial pulse pressure variation and continuous cardiac index trending reduces postoperative complications after major abdominal surgery: a multi-center, prospective, randomized study. Salzwedel 2013 160 PPV, CI 腹部 ProAQT-1 发病率 医院住院时长
Goal-directed fluid therapy in gastrointestinal surgery in older coronary heart disease patients: randomized trial. Zheng 2013 60 SVV, SVI, CI 腹部 FloTrac传感器-7 发病率 医院住院时长
Zakhaleva, J., et al., The impact of intravenous fluid administration on complication rates in bowel surgery within an enhanced recovery protocol: a randomized controlled trial. Colorectal Dis, 2013. 15(7): p. 892-9 91 SV 腹部外科 TED 发病率
Peng, K., et al., Goal-directed fluid therapy based on stroke volume variations improves fluid management and gastrointestinal perfusion in patients undergoing major orthopedic surgery. Med Princ Pract, 2014. 23(5): p. 413-20 80 SVV 骨外科 PC FloTrac传感器 胃肠道恢复
Zeng, K., et al., The influence of goal-directed fluid therapy on the prognosis of elderly patients with hypertension and gastric cancer surgery. Drug Des Devel Ther, 2014. 8: p. 2113-9 60 SVV 胃切除术 PC FloTrac传感器 发病率，医院住院时长
Colantonio, L., et al., A randomized trial of goal directed vs. standard fluid therapy in cytoreductive surgery with hyperthermic intraperitoneal chemotherapy. J Gastrointest Surg, 2015. 19(4): p. 722-9 80 CI, SVI 细胞减数外科 PC FloTrac传感器 发病率，医院住院时长
Funk, D.J., et al., A randomized controlled trial on the effects of goal-directed therapy on the inflammatory response open abdominal aortic aneurysm repair. Crit Care, 2015. 19: p. 247 40 SVV, CI 血管外科 PC FloTrac传感器 发病率
Mikor, A., et al., Continuous central venous oxygen saturation assisted intraoperative hemodynamic management during major abdominal surgery: a randomized, controlled trial. BMC Anesthesiol, 2015. 15: p. 82 79 ScvO2 腹部外科 CVC Cevox 死亡率和氧供
Han, G., et al., Application of LiDCO-Rapid in peri-operative fluid therapy for aged patients undergoing total hip replacement. International Journal of Clinical and Experimental Medicine, 2016. 9(2): p. 4473-4478 40 SVV 骨外科 PC LiDCO rapid 发病率
Hand, W.R., et al., Intraoperative goal-directed hemodynamic management in free tissue transfer for head and neck cancer. Head Neck, 2016. 38 Suppl 1: p. E1974-80 94 SVV, CI, SVR 游离组织外科 PC FloTrac传感器 ICU住院时长
Kapoor, P.M., et al., Perioperative utility of goal-directed therapy in high-risk cardiac patients undergoing coronary artery bypass grafting: “A clinical outcome and biomarker- based study”. Ann Card Anaesth, 2016. 19(4): p. 638-682 130 SVV, CI, SVI, SVRI, DO2 心脏外科 PC FloTrac传感器，中心静脉血氧饱和度导管（CVC） ICU住院时长，医院住院时长
Kumar, L., S. Rajan, and R. Baalachandran, Outcomes associated with stroke volume variation versus central venous pressure guided fluid replacements during major abdominal surgery. J Anaesthesiol Clin Pharmacol, 2016. 32(2): p. 182-6 60 SVV 腹部外科 PC FloTrac传感器 ICU住院时长
Osawa, E.A., et al., Effect of Perioperative Goal-Directed Hemodynamic Resuscitation Therapy on Outcomes Following Cardiac Surgery: A Randomized Clinical Trial and Systematic Review. Crit Care Med, 2016. 44(4): p. 724-33 126 CI, SVI 心脏外科 PC LidCO Rapid 发病率，ICU住院时长，医院住院时长
Yuanbo, Z., et al., ICU management based on PiCCO parameters reduces duration of mechanical ventilation and ICU length of stay in patients with severe thoracic trauma and acute respiratory distress syndrome. Annals of Intensive Care, 2016. 6(1): p. 113 264 ITBVI, EVLWI, CI ARDS ICU治疗 PC PiCCO MV天数，ICU住院时长，节省成本
Elgendy, M.A., I.M. Esmat, and D.Y. Kassim, Outcome of intraoperative goal-directed therapy using Vigileo/FloTrac in high-risk patients scheduled for major abdominal surgeries: A prospective randomized trial. Egyptian Journal of Anaesthesia, 2017 86 SVV, CI, MAP 腹部大手术 PC FloTrac传感器 发病率，ICU住院时长
Kapoor, P.M., et al., Goal-directed therapy improves the outcome of high-risk cardiac patients undergoing off-pump coronary artery bypass. Ann Card Anaesth, 2017. 20(1): p. 83-89 163 SVV, CI, ScvO2 心脏外科 VolumeView套件，PC FloTrac传感器 ICU住院时长，医院住院时长
Kaufmann, K.B., et al., Oesophageal Doppler guided goal-directed haemodynamic therapy in thoracic surgery - a single centre randomized parallel-arm trial. Br J Anaesth, 2017. 118(6): p. 852-861 100 SV, CI MAP 胸外科 TED 发病率，医院住院时长
Liang, M., et al., Effect of goal-directed fluid therapy on the prognosis of elderly patients with hypertension receiving plasmakinetic energy transurethral resection of prostate. Int J Clin Exp Med, 2017. 10(1): p. 1290-1296 60 SVV 泌尿外科-前列腺切除术 PC FloTrac传感器 发病率，医院住院时长
Luo, J., et al., Goal-directed fluid restriction during brain surgery: a prospective randomized controlled trial. Ann Intensive Care, 2017. 7(1): p. 16 145 SVV, CI 神经外科 PC FloTrac传感器 ICU住院时长，节省成本，发病率
Weinberg, L., et al., Restrictive intraoperative fluid optimisation algorithm improves outcomes in patients undergoing pancreaticoduodenectomy: A prospective multicentre randomized controlled trial. PLoS One, 2017. 12(9): p. e0183313 52 SVV, CI 腹部 PC FloTrac传感器 发病率，医院住院时长
Wu, C.Y., et al., Comparison of two stroke volume variation-based goal-directed fluid therapies for supratentorial brain tumour resection: a randomized controlled trial. Br J Anaesth, 2017. 119(5): p. 934-942 80 SVV 神经外科 PC FloTrac传感器 ICU住院时长，发病率
Wu, J., et al., Goal-directed fluid management based on the auto-calibrated arterial pressure-derived stroke volume variation in patients undergoing supratentorial neoplasms surgery. INTERNATIONAL JOURNAL OF CLINICAL AND EXPERIMENTAL MEDICINE, 2017. 10(2): p. 3106-3114 66 SVV, CI, MAP 脑外科 PC FloTrac传感器 发病率 乳酸

Edwards临床教育

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促进临床进步的血流动力学教育

始终致力于通过教育来改善外科和重症监护患者的护理质量，无论您在学习过程中的哪个阶段，Edwards临床教育都能向您提供一系列的资源和工具，在您目前和未来面临临床挑战时，可以为您不断提供支持。

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参考文献：
  1. Benes, J., Giglio M., Michard, F. (2014) The effects of goal-directed fluid therapy based on dynamic parameters on post-surgical outcome: a meta-analysis of randomized controlled trials. Critical Care, 18(5), 584
  2. Giglio, MT., Marucci, M., Testini, M., Brienza, N. (2009) Goal-directed haemodynamic therapy and gastrointestinal complications in major surgery: a meta-analysis of randomized controlled trials. British Journal of Anaesthesia, 103(5), 637-46
  3. Johnson, A., Ahrens, T. (2015) Stroke Volume Optimization: The New Hemodynamic Algorithm. Critical Care Nurse, 35(1), 11-27
  4. O’Leary, M. (2001) Preventing renal failure in the critically ill. BMJ, 322(7300), 1437-1439
  5. Holte, K. (2010) Pathophysiology and clinical implications of perioperative fluid management in elective surgery. Danish Medical Bulletin, 57(7), B4156
  6. Berkenstadt, H., et al. (2001) Stroke Volume Variation as a Predictor of Fluid Responsiveness in Patients Undergoing Brain Surgery. Anesthesia & Analgesia, 92, 984-9
  7. Cannesson, M. (2010) Arterial pressure variation and goal-directed fluid therapy. Journal of Cardiothoracic and Vascular Anesthesia, 24(3), 487-97
  8. Peng, K., Li, J., Cheng, H., Ji, FH. (2014) Goal-directed fluid therapy based on stroke volume variations improves fluid management and gastrointestinal perfusion in patients undergoing major orthopedic surgery. Medical Principles and Practice, 23(5), 413-20
  9. Ghaferi, A., Birkmeyer, J., Dimick, J. (2009) Variation in hospital mortality associated with inpatient surgery. New England Journal of Medicine, 361(14), 1368-75
  10. Khuri, S., Henderson, W., DePalma, R., Mosca, C., Healey, N., Kumbhani, D. (2005) Determinants of long-term survival after major surgery and the adverse effect of postoperative complications. Annals of Surgery, 242(3), 326-41
  11. Aya, H., Cecconi, M., Hamilton, M., Rhodes, A. (2013) Goal-directed therapy in cardiac surgery: a systematic review and meta-analysis. British Journal of Anaesthesia, 110(4), 510-7
  12. Brienza, N., Giglio, M., Marucci, M., Fiore, T. (2009) Does perioperative hemodynamic optimization protect renal function in surgical patients? A meta-analytic study. Critical Care Medicine, 37(6), 2079-90
  13. Grocott, M., Dushianthan, A., Hamilton, M., Mythen, M., Harrison, D., Rowan, K. (2012) Perioperative increase in global blood flow to explicit defined goals and outcomes following surgery. Cochrane Database of Systematic Reviews, 11, CD004082
  14. Corcoran, T., Rhodes, J., Clarke, S., Myles, P., Ho, K. (2012) Perioperative fluid management strategies in major surgery: a stratified meta-analysis. Anesthesia & Analgesia, 114(3), 640-51
  15. Boltz, M., Hollenbeak, C., Ortenzi, G., Dillon, P. (2012) Synergistic implications of multiple postoperative outcomes. American Journal of Medical Quality, 27(5), 383-90
  16. Bellamy, M. (2006) Wet, dry or something else? British Journal of Anaesthesia, 97(6), 755-7
  17. Ping W, et al. Effects of Stroke Volume Variability-Guided Intraoperative Fluid Restriction on Gastrointestinal Functional Recovery. Chinese Journal of Anesthesiology 31.1 (2011): 78-81.
  18. Thacker JKM, et al. Perioperative Fluid Utilization Variability and Association With Outcomes. Annals of Surgery 263.3 (2016): 502-510.
  19. Durairaj L and Schmidt GA. Fluid Therapy in Resuscitated Sepsis*. Less is More. Recent Advances in Chest Medicine. 133.1 (2008): 252-263.
  20. Li, Cheng, et al. Stroke Volume Variation for Prediction of Fluid Responsiveness in Patients Undergoing Gastrointestinal Surgery. International Journal of Medical Sciences. 2013; 10(2): 148-155.

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