重症成人脓毒症的液体治疗（JAMA）

Fluid Therapy for Critically Ill Adults With Sepsis A Review

IMPORTANCE Approximately 20% to 30% of patients admitted to an intensive care unit have sepsis. While fluid therapy typically begins in the emergency department, intravenous fluids in the intensive care unit are an essential component of therapy for sepsis.

OBSERVATIONS For patients with sepsis, intravenous fluid can increase cardiac output and blood pressure, maintain or increase intravascular fluid volume, and deliver medications. Fluid therapy can be conceptualized（使概念化） as 4 overlapping（重叠的） phases from early illness through resolution of sepsis: resuscitation (rapid fluid administered to restore perfusion)【复苏(快速输注以恢复灌注)】; optimization (the risks and benefits of additional fluids to treat shock and ensure organ perfusion are evaluated)【优化(评估治疗休克的额外液体的风险和利益，确保器官灌注)】; stabilization (fluid therapy is used only when there is a signal of fluid responsiveness)【稳定(液体疗法仅在有液体反应信号时使用)】; and evacuation (excess fluid accumulated during treatment of critical illness is eliminated)【撤退(危重病治疗过程中积聚的多余液体被排出)】. Among 3723 patients with sepsis who received 1 to 2 L of fluid, 3 randomized clinical trials (RCTs) reported that goal-directed therapy administering fluid boluses to attain a central venous pressure of 8 to 12 mmHg, vasopressors to attain a mean arterial blood pressure of 65 to 90 mmHg, and red blood cell transfusions（输注） or inotropes（强心药物） to attain a central venous oxygen saturation（中心静脉血氧饱和度） of at least 70% did not decrease mortality compared with unstructured clinical care (24.9% vs 25.4%; P = .68). Among 1563 patients with sepsis and hypotension who received 1 L of fluid, an RCT reported that favoring vasopressor treatment did not improve mortality compared with further fluid administration (14.0% vs 14.9%; P = .61). Another RCT reported that among 1554 patients in the intensive care unit with septic shock treated with at least 1 L of fluid compared with more liberal（宽宏大度的） fluid administration, restricting（限制） fluid administration in the absence of（没有） severe hypoperfusion did not reduce mortality (42.3% vs 42.1%; P = .96). An RCT of 1000 patients with acute respiratory distress during the evacuation phase reported that limiting fluid administration and administering diuretics（注射利尿剂） improved the number of days alive without mechanical ventilation compared with fluid treatment to attain higher intracardiac（心脏内的） pressure (14.6 vs 12.1 days; P < .001), and it reported that hydroxyethyl starch（羟乙基淀粉） significantly increased the incidence of kidney replacement therapy compared with saline (7.0% vs 5.8%; P = .04), Ringer lactate（乳酸林格）, or Ringer acetate（醋酸林格）.

CONCLUSIONS AND RELEVANCE Fluids are an important component of treating patients who are critically ill with sepsis. Although optimal fluid management in patients with sepsis remains uncertain, clinicians should consider the risks and benefits of fluid administration in each phase of critical illness, avoid use of hydroxyethyl starch, and facilitate（促进） fluid removal for patients recovering from acute respiratory distress syndrome.