Controversies in fluid therapy: Type, dose and toxicity  

作　　者：Robert C McDermid Karthik Raghunathan Adam Romanovsky Andrew D Shaw Sean M Bagshaw 

机构地区：[1]Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB T6G2B7, Canada [2]Department of Anesthesiology, Duke University Medical Center/Durham VAMC, Durham, NC 90484, United States [3]Department of Critical Care Medicine, Duke University Medical Center/Durham VAMC, Durham, NC 90484, United States

出　　处：《World Journal of Critical Care Medicine》2014年第1期24-33,共10页世界重症医学杂志

基　　金：Supported by Canada Research Chair in Critical Care Nephrology;Clinical Investigator Award from Alberta Innovates-Health Solutions to Bagshaw MS

摘　　要：Fluid therapy is perhaps the most common intervention received by acutely ill hospitalized patients; however, a number of critical questions on the efficacy and safety of the type and dose remain. In this review, recent insights derived from randomized trials in terms of fluid type, dose and toxicity are discussed. We contend that the prescription of fluid therapy is context-specific and that any fluid can be harmful if administered inappropriately. When contrasting ‘‘crystalloid vs colloid'', differences in efficacy are modest but differences in safety are significant. Differences in chloride load and strong ion difference across solutions appear to be clinically important. Phases of fluid therapy in acutely ill patients are recognized, including acute resuscitation, maintaining homeostasis, and recovery phases. Quantitative toxicity(fluid overload) is associated with adverse outcomes and can be mitigated when fluid therapy basedon functional hemodynamic parameters that predict volume responsiveness and minimization of non-essential fluid. Qualitative toxicity(fluid type), in particular for iatrogenic acute kidney injury and metabolic acidosis, remain a concern for synthetic colloids and isotonic saline, respectively. Physiologically balanced crystalloids may be the ‘‘default'' fluid for acutely ill patients and the role for colloids, in particular hydroxyethyl starch, is increasingly unclear. We contend the prescription of fluid therapy is analogous to the prescription of any drug used in critically ill patients.Fluid therapy is perhaps the most common intervention received by acutely ill hospitalized patients; however, a number of critical questions on the efficacy and safety of the type and dose remain. In this review, recent insights derived from randomized trials in terms of fluid type, dose and toxicity are discussed. We contend that the prescription of fluid therapy is context-specific and that any fluid can be harmful if administered inappropriately. When contrasting ‘‘crystalloid vs colloid'', differences in efficacy are modest but differences in safety are significant. Differences in chloride load and strong ion difference across solutions appear to be clinically important. Phases of fluid therapy in acutely ill patients are recognized, including acute resuscitation, maintaining homeostasis, and recovery phases. Quantitative toxicity(fluid overload) is associated with adverse outcomes and can be mitigated when fluid therapy basedon functional hemodynamic parameters that predict volume responsiveness and minimization of non-essential fluid. Qualitative toxicity(fluid type), in particular for iatrogenic acute kidney injury and metabolic acidosis, remain a concern for synthetic colloids and isotonic saline, respectively. Physiologically balanced crystalloids may be the ‘‘default'' fluid for acutely ill patients and the role for colloids, in particular hydroxyethyl starch, is increasingly unclear. We contend the prescription of fluid therapy is analogous to the prescription of any drug used in critically ill patients.

关 键 词：Fluid therapy RESUSCITATION Critical illness PERI-OPERATIVE Toxicity SALINE CRYSTALLOID COLLOID 

分 类 号：R457.2[医药卫生—治疗学]