Chinese Society of Critical Care Medicine-CSCCM 10th Anniversary

讲座摘要

感染患者的扩容治疗 Plasma expansion in septic patients

Bertrand Guidet

讲座课件

Address correspondence to

Pr Bertrand Guidet

Hôpital Saint Antoine Paris

184 Rue du Fg Saint Antoine

Tel : 33 1 49 28 23 19

E-mail: bertrand.guidet@sat.aphp.fr

Abstract

Intensive care patients with hypovolemia, related to sepsis deserve a global approach.

Fluid resuscitation is part of the treatmen., but the respective contribution of volume expansion and vaso-active drugs in the restoration of blood pressure and cardiac output is still a matter of debate.

Which volume and type of solution should be used, which preload should be targeted?

No single trial has documented a clear superiority of a plasma substitute in term of mortality, length of stay or length of mechanical ventilation.

The meta-analysis comparing crystalloids and colloids in term of mortality, have several flaws and document only a superiority of crystalloids for trauma patients.

In intensive care, the choice of a colloid relies on the macro and microcirculatory properties, duration of action, tolerance and price of plasma expanders.

Human albumin, a natural colloid, does not expand plasma volume better than dextrans or hydroxyethyl starches (HES) but has a much higher cost justifying limiting its use.

Among synthetic colloids, dextrans have two major drawbacks: severe allergic reactions and hemostasis effects.

Gelatins have no dose limitation but the duration of action is short, the rheologic effect is unfavorable and allergic reaction rate higher than with other colloids.

HES have a half life related to intravascular hydrolysis which depends on molar substitution.

They induce few allergic reactions and the new low molar substituted HES (130/0.4) have no effect on hemostasis.

During plasma expansion, peripheral and pulmonary edema may occur.

In fact, the normal lungs are well protected since the lymphatic drainage is rich and the transcapillary oncotic gradient is maintained even if plasma colloido osmotic pressure (COP) is half normal values.

However, a major drop of plasma COP leads to a decrease of the hydrostatic pressure threshold for pulmonary edema.

When, the capillary membrane is altered, the hydrostatic pressure is the main determinant of the fluid flux across the membrane.

Whether new starches have a favorable effect in this situation needs to be evaluated.

In summary, the goal of plasma expansion in hypovolemia is to restore an adequacy between oxygen transport and consumption.

The choice of a plasma substitute should rely on hemodynamic response, tolerance and cost.

According to these considerations, albumin should have very restricted indications and new medium molecular weight starches with low molar substitution infused together with crystalloids should be preferred.

References

Martin Westphal, Michael F. M. James, et al. Hydroxyetbyl Starcbes. Anesthesiology 2009; 111:187-202.

第二届中法危重病医学研讨会暨上海重症医学论坛（2009年12月中国上海）