国际标准化急诊初级医生训练营：病例10 液体复苏

CASE 10: INTRAVENOUS FLUID RESUSCITATION

液体复苏

History

病史

A 48-year-old male was the driver in a head-on collision between two cars travelling at 45 miles

per hour. He has an open tibial fracture and a distended and bruised abdomen. During the pri

mary survey in the Emergency Department, it is noted that he is hypotensive and tachycardic.

A decision is made to initiate fluid resuscitation.

48岁男患以45英里时速驾驶时与对面汽车迎头相撞，来院时一侧开放性胫骨骨折，腹部皮肤青紫及腹胀明显。急诊初步评估提示患者低血压及心动过速，根据ABCDE原则，立即予液体复苏以改善休克状态。

Questions

1. What is the content of 0.9% saline and Hartmann’s solution?

0.9%氯化钠溶液 、乳酸林格氏液的成分是什么

2. How is water distributed in the body?

液体进入人体后是如何分布的

3. How is 1 L of crystalloid fluid distributed in the body? How is 1 L of 5% dextrose

solution distributed in the body? How is 1 L of blood distributed in the body? 

1L晶体液在人体的分布，1L5%葡萄糖在人体的分布，1L 血制品在人体的分布

DISCUSSION

讨论

Intravenous fluids can be divided into crystalloids and colloids. Crystalloids are made up of

water-soluble molecules (e.g. saline solution, Hartmann’s solution). Colloid fluids contain

insoluble molecules (e.g. Gelofusin, which contains gelatin).

常用复苏液分为两类 晶体液及胶体液。晶体液由水溶性分子物质及水组成，如等渗氯化钠溶液及乳酸林格液；胶体液包含非水溶性分子，如动物胶制品。

Saline solution (0.9% sodium chloride) contains both sodium (154 mmol/L) and chloride

(154 mmol/L). Hartmann’s solution contains the following: sodium 131 mmol/L, chloride 111

mmol/L, potassium 5 mmol/L, calcium 2 mmol/L and bicarbonate 29 mmol/L (which is supplied in the form of lactate, which is then metabolised to bicarbonate).

0.9%氯化钠溶液包含 154mmol/L Na 154mmol/L Cl，乳酸林格 含 131mmol/L Na ,111 mmol/L Cl,,,,,, 5mmol/L K,,,,,,2mmol/L Ca.............29mmol/L  NaHCO3(以乳酸形式存在于溶液中，，，进入人体后代谢为NaHCO3)

Sixty percent percent of the human body mass is composed of water, of which two-thirds lies

in the intracellular compartment and one-third lies in the extracellular compartment. 

 人体体重60%为自由水，2/3存在于细胞内，，，1/3存在于细胞外。

Te extracellular compartment is further subdivided into interstitial fluid (75%) and intravascular fluid (25%). 

细胞外分为 存在于血管外的间质液75% ，，，，血管内液 25%

Tus, a 70 kg human will have 42 L of total body water (60% of mass), of which

28 L (two-thirds) is intracellular and 14 L (one-third) is extracellular. Of the extracellular

water, 10.5 L (75%) is interstitial and 3.5 L (25%) is intravascular fluid.

以一个70kg 的人为例  70X60%  总体液为 42L  ，42X2/3 细胞内液 28L  余下42X1/3为细胞外液 即 14L，，，，

细胞外液 的14LX75% 为间质液 即 10.5L。。。。。14X25% 为血管内液体 即 3.5L   即正常状态下一个人总的血容量是非常少的。。。。。

To calculate what volume of 1 L of crystalloid such as saline 0.9% or Hartmann’s solution enters the intravascular space, the above principles apply. Te sodium content of both of these fluids is similar to plasma, which means the entire 1 L of fluid will be distributed amongst the extracellular compartment. 

Thus, 750 mL (75%) will be interstitial, and 250 mL (25%) will be intravascular. Five percent of dextrose or glucose solutions are distributed relative to total body water, so that 666.6 mL is intracellular and 333.3 mL is extracellular. Of the extracellular fluid, 250 mL is interstitial and 83.3 mL is intravascular. Of note,when administering a blood transfusion, all of the content is distributed in the intravascular space, making it ideal for hypotensive resuscitation.

1L晶体液，如0.9%氯化钠溶液及乳酸林格液进行血管循环后，适于上述正常人体体液分布的百分比。这两种含钠晶体液钠浓度与血浆类似，即进入人体后主要分布在细胞外液。即750ml进入人体后分布于间质，，，，，250ml分布于 血管内。。。5%葡萄糖液主要分布于全身，即666.6ml在细胞内液，，，333.3ml分布于细胞外液，，，250ml分布于间质，只有83.3ml分布于 血管内。。。非常的少。。。。。所以临床上为什么用盐为扩容而不是用糖，晶体扩容效应是糖的3倍。而血液制品，如红细胞及白蛋白、血浆等，只分布于血管内，所以是最理想的扩容复苏液体。

Te disadvantage of using colloids such as Gelofusin is that they contain insoluble proteins that can cause bleeding disorders, interfere with blood cross-matching and may lead to anaphylaxis. 

胶体液的缺点是非可溶性蛋白质 可引起凝血异常，，，干扰交叉配血的准确性，以及引起过敏性休克。

Although colloids provide more initial intravascular expansion, it is now accepted that there is no signifcant difference in reducing mortality when using crystalloids or colloids for fluid resuscitation. 

胶体液初始有扩容的作用，目前普遍认为复苏时 胶体液相比晶体液并不能降低死亡率

Tis was demonstrated in the Saline versus Albumin Fluid Evaluation (SAFE) Study (2004), which showed that albumin (colloid) and saline (crystalloid) should be considered clinically equivalent treatments for intravascular volume resuscitation in a heterogeneous population of patients in the Intensive Care Unit. 

依据来源于2004年 Saline versus Albumin Fluid Evaluation (SAFE) RCT研究的循证学结论，显示白蛋白 相比 生理盐水在ICU不同患者的血管容量复苏使用时，临床效应相似。

Further studies on fluid resuscitation of patients with traumatic brain injury have shown that colloids are associated with a higher mortality than crystalloids.

进一步的研究显示创伤性脑损伤的患者，胶体液比晶体液导致更高的死亡率。

Key Points  

关键要素

• When resuscitating a hypotensive patient, using 1 L of crystalloid will equate to 250

mL of intravascular fluid; using 1 L of dextrose 5% will equate to less than 100 mL

of intravascular fluid; and using 1 L of blood will equate to 1 L of intravascular fluid.

低血压复苏时，1L晶体液增加250ml血管内容量；1L 5%葡萄糖增加少于100ml的血管内容量；1L血制品复苏时增加1L的血管内容量

• Advanced Trauma Life Support (ATLS) guidelines and the SAFE study recommend

crystalloid instead of colloid fluid resuscitation. Crystalloids are cheaper and do

not exhibit the same disadvantages (blood clotting disorders and anaphylaxis) as

colloids  

ATLS 高级创伤生命支持指南及SAFE研究推荐 使用晶体液复苏，而不是胶体液。晶体液更便宜，同时没有胶体液的不良反应，胶体液影响凝血及引起过敏。