低血容量休克复苏指南(2007)

1.  简 介

低血容量休克是指各种原因引起的外源性和/或内源性容量丢失而导致的有效循环血量减少、组织灌注不足、细胞代谢紊乱和功能受损的病理生理过程。近三十年来,低血容量休克的治疗已取得较大进展,然而,其临床死亡率仍然较高[1,2,3]。低血容量休克的主要死因是低灌注以及大出血、感染和再灌注损伤等原因导致的MODS[2,3,4]。目前,低血容量休克缺乏较全面的流行病学资料。创伤失血是低血容量休克最常见的原因。据国外统计,创伤导致的失血性休克死亡人数占创伤总死亡数的10~40%[5-7]

低血容量休克的主要病理生理改变是有效循环血容量急剧减少,导致组织低灌注,无氧代谢增加、乳酸性酸中毒,再灌注损伤[5,6],以及内毒素移位 [5],细胞损伤,最终导致MODS[6,7]。低血容量休克的最终结局自始至终与组织灌注相关,因此,提高其救治率的关键在于尽早去除休克病因的同时,尽快恢复有效的组织灌注,以改善组织细胞的氧供,重建氧的供需平衡和恢复正常的细胞功能。

本指南旨在根据低血容量休克的最新循证医学进展,推荐临床诊断,监测以及治疗的共识性意见,以利于低血容量休克的临床规范化管理。推荐级别依据Delphi分级法[8](见表1)。

 

表1  推荐级别与研究文献的Delphi分级

推荐级别
A           至少有2项Ⅰ级研究结果支持

B           仅有1项Ⅰ级研究结果支持

C           仅有Ⅱ级研究结果支持

D           至少有1项III级研究结果支持

E           仅有Ⅳ级或Ⅴ级研究结果支持

 

研究文献的分级
Ⅰ          大样本、随机研究、结论确定,假阳性或假阴性错误的风险较低

Ⅱ          小样本、随机研究、结论不确定,假阳性和/或假阴性错误的风险较低

III          非随机,同期对照研究

Ⅳ          非随机,历史对照研究和专家意见

Ⅴ          系列病例报道,非对照研究和专家意见

推荐意见1:临床医师应该熟悉与重视低血容量休克。(E级)

2.病因与早期诊断

低血容量休克的循环容量丢失包括外源性和内源性丢失。外源性丢失是指循环容量丢失至体外,失血是典型的外源性丢失。如创伤、外科大手术的失血、消化道溃疡、食道静脉曲张破裂、动脉瘤、宫外孕及产后大出血等疾病引起的急性大失血等。外源性丢失也可以由呕吐、腹泻、脱水、利尿等原因所致。内源性容量丢失是指循环容量丢失到循环系统之外,但仍然在体内,其原因主要为血管通透性增高,循环容量的血管外渗出或循环容量进入体腔内[9]

低血容量休克的早期诊断,对预后至关重要。传统的诊断主要依据病史、症状、体征,包括精神状态改变,皮肤湿冷,收缩压下降(<90mmHg或较基础血压下降40mmHg)或脉压差减少(<20mmHg),尿量<0.5ml/hr·kg,心率>100次/分,CVP<5mmHg或PAWP<8mmHg等指标[10]。然而,传统诊断标准的局限性已被人们充分认识。近年来,人们认识到氧代谢与组织灌注指标对低血容量休克早期诊断的重要参考价值,血乳酸(>2mmol/L)、碱缺失(<-5mmol/L)[37,43-44, 123-4]是低血容量休克早期诊断的重要指标。对于每搏量(SV)、心排量(CO)、氧输送(DO2)、氧消耗(VO2)、胃粘膜CO2张力(PgCO2)、混合静脉血氧分压(SVO2)等指标,人们也认识到具有一定程度的临床意义,尚需要进一步循证医学证据支持。

低血容量休克的发生与否极其程度,取决于机体血容量丢失的多少和速度。以失血性休克为例估计血容量的丢失,见表2。成人的平均估计血容量占体重的7%(或70 ml/kg)[11]。一个70kg体重的人约有5L的血液。血容量随着年龄和生理状况而改变。以占体重的百分比为参考指数时,高龄人的血容量较少(占体重的6%左右)。而儿童的血容量占体重的8-9%,新生儿估计血容量占体重的9-10%[12]。可根据失血量等指标将失血分成四级[13]。大量失血可以定义为24小时内失血超过患者的估计血容量或3小时内失血量超过估计血容量的一半。

表2.失血的分级(以70公斤为例)

参数 IV
失血量(ml) <750 750–1500 1500–2000 >2000
失血量(%) <15% 15–30% 30–40% >40%
心率(bpm) <100 >100 >120 >140
血压 正常 下降 下降 下降
呼吸频率(bpm) 14–20 20–30 30–40 >40
尿量(ml/hr) >30 20–30 5–15 无尿
神经系统 轻度焦虑 中度焦虑 萎靡 昏睡

推荐意见2:传统诊断指标对低血容量休克的早期诊断有一定的局限性(C级)。

推荐意见3:低血容量休克的早期诊断,应该重视血乳酸与碱缺失检测(C级)。

3.病理生理

有效循环血容量丢失触发机体各系统器官产生一系列病理生理反应,以保存体液,维持灌注压,保证心、脑重要器官的血液灌流[14,15]

低血容量导致交感神经-肾上腺轴兴奋,儿茶酚胺类激素释放增加并选择性地收缩皮肤、肌肉及内脏血管。其中动脉系统收缩使外周血管总阻力升高以提升血压;毛细血管前括约肌收缩导致毛细血管内静水压降低,从而促进组织间液回流;静脉系统收缩使血液驱向中心循环,增加回心血量。儿茶酚胺类激素使心肌收缩力加强,心率增快,心排血量增加。

低血容量兴奋肾素-血管紧张素Ⅱ-醛固酮系统,使醛固酮分泌增加,同时刺激压力感受器促使垂体后叶分泌抗利尿激素,从而加强肾小管对钠和水的重吸收,减少尿液,保存体液。

上述代偿反应在维持循环系统功能相对稳定,保证心、脑等重要生命器官的血液灌注的同时,也具有潜在的风险[14,15]。这些代偿机制使血压下降在休克病程中表现相对迟钝和不敏感,导致若以血压下降作为判定休克的标准,必然贻误对休克的早期认识和救治。同时,代偿机制对心、脑血供的保护是以牺牲其他脏器血供为代价,持续肾脏缺血可以导致急性肾损害,胃肠道粘膜缺血可以诱发细菌、毒素移位[14-16],内毒素血症与缺血-再灌注损伤诱发大量炎性介质释放入血,促使休克向不可逆发展[16-19]

机体对低血容量休克的反应还涉及代谢、免疫、凝血等系统[14,15],同样也存在对后续病程的不利影响。肾上腺皮质激素和前列腺素分泌增加与泌乳素分泌减少可以造成免疫功能抑制,患者易于受到感染侵袭。缺血缺氧、再灌注损伤等病理过程导致凝血功能紊乱并有可能发展为弥漫性血管内凝血。

组织细胞缺氧是休克的本质[14-15,20]。休克时微循环严重障碍,组织低灌注和细胞缺氧,糖的有氧氧化受阻,无氧酵解增强,ATP 生成显著减少,乳酸生成显著增多,导致乳酸性酸中毒,进而造成组织细胞和重要生命器官发生不可逆性损伤,直至发生MODS。

推荐意见4:应当重视低血容量休克病程中生命体征正常状态下的组织细胞缺氧。(E)

 

4.组织氧输送与氧消耗

低血容量休克时,由于有效循环血容量下降,导致心输出量下降,因而氧输送(DO2)下降。对失血性休克而言,DO2下降程度不仅取决于心输出量,同时受血红蛋白下降程度影响。

在低血容量休克、DO2下降时,氧消耗(VO2)是否下降尚没有明确结论。由于组织器官的氧摄取增加-表现为氧摄取率(O2ER)和动静脉氧分压差(a-vDO2)的增加,当DO2未下降到一定阈值前,组织器官的氧耗(VO2)能基本保持不变。DO2下降到一定阈值时,即使氧摄取明显增加,也不能满足组织氧耗。

血红蛋白下降时,动脉血氧分压(PaO2)对血氧含量的影响增加,进而影响DO2。因此,通过氧疗增加血氧分压应该对提高氧输送有效[21]

有研究表明,在外科术后高危患者及严重创伤患者进行了以超高氧输送(supranormal)为复苏目标的研究,结果可以减少死亡率[3,22]。但是,也有许多研究表明,与以正常氧输送为复苏目标相比,超高氧输送并不能降低死亡率。有研究认为两者结果是相似的,甚至有研究认为可能会增加死亡率[23-25]。最近,Kern回顾了众多RCT的研究发现,尽早复苏(在出现器官衰竭前)可以减低死亡率,对其中病情更为严重的患者可能更有效[26]

推荐意见5:低血容量休克早期复苏的目的是尽早改善氧输送。(C级)

5.监测

有效的监测可以对低血容量休克的病情和治疗反应做出正确及时的评估和判断,以利于指导和调整治疗计划,改善患者的预后。

5.1一般临床监测

包括皮温与色泽、心率、血压、尿量和精神状态等监测指标。然而,这些指标在休克早期阶段往往难以看到明显的变化。

皮温下降、皮肤苍白、皮下静脉塌陷的严重程度取决于休克的严重程度。但是,这些症状并不是低血容量休克的特异性症状。

心率加快通常是休克的早期诊断指标之一,但是心率不是判断失血量多少的可靠指标。比如较年轻的患者可以很容易的通过血管收缩来代偿中等量的失血,仅表现为轻度心率增快。

血压的变化需要严密地动态监测。休克初期由于代偿性血管收缩,血压可能保持或接近正常。有研究[27]支持对未控制出血的失血性休克维持“可允许性低血压” (permissive  hypotention)。然而,对于可允许性低血压究竟应该维持在什么标准,由于缺乏血压水平与机体可耐受时间的关系方面深入的研究,至今尚没有明确的结论。目前一些研究认为,维持平均动脉压(MAP)在60-80mmHg [28,29] 比较恰当。

尿量是反映肾灌注较好的指标,可间接反映循环状态。当每小时尿量低于0.5ml/kg/h 时,应继续液体复苏。需注意临床上出现休克而无少尿的情况,如高血糖和造影剂等有渗透活性的物质造成的渗透性利尿。

体温监测亦十分重要,一些临床研究则认为低体温是有害的,可引起心肌功能障碍和心律失常,当中心体温低于34C时,可产生严重的凝血功能障碍。[30,31]

 

5.2有创血流动力学监测

平均动脉压(MAP)监测:一般来说,有创动脉血压(IBP)较无创动脉血压(NIBP)高5~20 mmHg 。低血容量休克时,由于外周血管阻力增加,NIBP测压误差较大,IBP测压可靠,可连续监测血压及变化。此外,IBP还可提供动脉采血通道。

中心静脉压(CVP)和肺动脉楔压(PAWP)监测:用于监测容量状态和指导补液,有助于了解机体对液体复苏的反应性,及时调整治疗,并有助于已知或怀疑存在心力衰竭的休克患者的液体治疗,防止过多输液导致的肺水肿。

心排出量(CO)和每搏量(SV)监测:休克时,CO与SV可有不同程度降低。[26]连续地监测CO与SV,有助于动态判断容量复苏的临床效果与心功能状态。

近年来有较多研究表明, 受多种因素的影响,CVP和PAWP与心脏前负荷的相关性不够准确。目前的一些研究显示,通过监测收缩压变化率(SPV)[32]、每搏量变化率(SVV) [33] 、脉压变化率(PPV) 、血管外肺水(EVLW)[34] 、胸腔内总血容量(ITBV)

[33] 进行失血性休克时患者的液体管理可能比传统方法更为可靠和有效。而对于正压通气的患者,应用SPV 、SVV与PPV则可能具有更好的容量状态评价作用。 Variation in amplitude of central venous pressure curve induced by respiration is a useful tool to reveal fluid responsiveness in postcardiac surgery patients.Westphal GA ,et al.Shock. 2006 Aug;26(2):140-5.

值得强调的是,任何一种监测方法所得到的数值都是相对的,因为各种血流动力学指标经常受到许多因素的影响。单一指标的数值有时并不能正确反映血流动力学状态,必须重视血流动力学的综合评估。在实施综合评估时,应注意以下三点:①结合症状、体征综合判断;②分析数值的动态变化;③多项指标的综合评估。

 

 

推荐意见6:对于低血容量休克,应尽早采用有创血压监测和中心静脉压监测。(E级)

推荐意见7:低血容量休克的患者需要严密的血流动力学监测并动态观察其变化。(E级)

 

5.3氧代谢监测: 休克的氧代谢障碍概念是对休克认识的重大进展,氧代谢的监测发展改变了休克的评估方式,同时使休克的治疗由以往狭义的血流动力学指标调整转向氧代谢状态的调控 。传统临床监测指标往往不能对组织氧合的改变具有敏感的反应。此外,经过治疗干预后的心率、血压等临床指标的变化也可在组织灌注与氧合未改善前趋于稳定。因此,应同时监测和评估一些全身灌注指标(DO2、VO2、血乳酸、SvO2或ScvO2等)以及局部组织灌注指标(胃粘膜pHi或消化道粘膜PCO2等)。

脉搏氧饱合度(SPO2):SPO2主要反映氧合状态,可在一定程度上表现组织灌注状态。低血容量休克的患者常存在低血压、四肢远端灌注不足、氧输送能力下降或者给予血管活性药物的情况,影响SPO2的精确性[35]

动脉血气分析:根据动脉血气分析结果,可鉴别体液酸碱紊乱性质,及时纠正酸碱平衡,调节呼吸机参数。BE可间接反映血乳酸的水平。当休克导致组织供血不足时BE下降,提示乳酸血症的存在[36] 。BE与血乳酸结合是判断休克组织灌注较好的方法。[37,38]

DO2

SVO2的监测:DO2 、SvO2 可作为低血容量休克早期复苏效果评估的良好指标,动态监测有较大意义[39]。 ScVO2与 SVO2 有一定的相关性,前者已经被大量研究证实是指导严重感染和感染性休克液体复苏的良好指标。但是,对低血容量休克的液体复苏的指导价值缺少有力的循证医学证据[40]

动脉血乳酸监测:动脉血乳酸浓度是反映组织缺氧的高度敏感的指标之一,动脉血乳酸增高常较其他的休克征象先出现。持续动态的动脉血乳酸监测对休克的早期诊断、判定组织缺氧情况、指导液体复苏及预后评估有重要意义[41]。但是,仅以血乳酸浓度尚不能充分反映组织的氧合状态,如合并肝功能不全的患者。研究显示在创伤后失血性休克的患者,血乳酸水平及高乳酸持续时间与器官功能障碍的程度及死亡率相关[42-44]

胃肠粘膜内pHi和PgCO2的监测: pHi和PgCO2能够反映肠道组织的血流灌注情况和病理损害,同时能够反映出全身组织的氧合状态,对评价胃肠道粘膜内的代谢情况,评估复苏效果有一定的价值 [45,46]

推荐意见8:低血容量休克的监测应重视血乳酸以及碱缺失水平与持续时间(C级)

 

5.4实验室监测:

血常规监测:动态观察红细胞计数、血红蛋白(Hb)及红细胞压积(HCT)的数值变化,可了解血液有无浓缩或稀释,对低血容量休克的诊断和判断是否存在继续失血有参考价值。血红蛋白(Hb)<70g/L,应给予输血治疗[47]。有研究表明[48]HCT在4小时内下降10%提示有活动性出血。

电解质监测与肾功能监测:对了解病情变化和指导治疗十分重要。

凝血功能监测:

在休克早期即进行凝血功能的监测,对选择适当的容量复苏方案及液体种类有重要的临床意义。有研究 [49]认为血栓弹力描记图(TEG)结果和创伤程度评分(injury severity score ,ISS) 与血小板记数、PT、APTT以及受伤来源相比, 更能提示伤后第一个24h内血液输注的危险性高低。TEG是一种新型简易的监测创伤患者凝血功能的参数之一。

 

6.治疗

6.1病因治疗

休克所导致的组织器官损害的程度与容量丢失量和持续时间直接相关。如果休克持续存在,组织缺氧不能缓解,休克的病理生理特征将发生进一步改变。所以,尽快纠正引起容量丢失的病因是治疗低血容量休克的基本措施。以创伤或失血性休克的相关研究很多,在创伤后存在进行性失血需要急诊手术的患者,多项研究表明尽可能缩短创伤和进入手术室的时间能够改善预后,提高存活率[50-52]。另有研究表明,对医生进行“60分钟急诊科时间限制”培训后,可以明显降低失血性休克患者的死亡率[53]。一个大样本的回顾分析发现:在手术室死亡的创伤失血患者主要原因是延迟入室,并且应该能够避免[54]。进一步研究提示,对于出血部位明确的失血性休克患者,早期进行手术止血非常必要,一个包括271例的回顾对照研究提示早期手术止血可以提高生存率 [55]。对于存在失血性休克又无法确定出血部位的患者,进一步评估很重要。因为只有早期发现、早期诊断才能早期进行处理,目前的临床研究认为,对于多发创伤和以躯干为主的失血性休克患者,床边超声可以早期明确出血部位从而早期提示手术的指征[56,57];另有研究提示: CT检查比床边超声有更好的特异性和敏感性 [58-60]

推荐意见9:积极纠正低血容量休克的病因是治疗的基本措施。(推荐级别:D)

推荐意见10:对于出血部位明确、存在活动性失血的休克患者,应尽快进行手术或介入止血(推荐级别:D)

推荐意见11:对于出血部位不明确、存在活动性失血的休克患者,应进一步检查和评估(推荐级别:D)

6.2液体复苏

液体复苏治疗时可以选择两种液体:晶体溶液(如生理盐水和等张平衡盐溶液) 和胶体溶液(如白蛋白和人工胶体)。由于5 %葡萄糖溶液很快分布到细胞内间隙,因此不推荐用于复苏治疗。

6.2.1. 晶体液: 液体复苏治疗常用的晶体液为0.9 %生理盐水和乳酸林格氏液 。在理想情况下,输注晶体液后会进行血管内外再分布,约有25 %存留在血管内,而其余75 %则分布于血管外间隙。因此低血容量休克时若以大量晶体液进行复苏,可以引起血浆蛋白的稀释以及胶体渗透压的下降,同时出现组织水肿,但应用两者的液体复苏的效果没有明确差异[61]。另外,0.9 %生理盐水优点是等渗,含氯高,大量输注可引起高氯性代谢性酸中毒[62-64];乳酸林格氏液优点在于电解质组成接近生理,为轻度低渗,同时含有少量的乳酸,一般情况下,其所含乳酸可在肝脏迅速代谢,大量输注乳酸林格氏液应该考虑到其对血乳酸水平的影响。

高张盐溶液复苏的现代概念起源于80年代 ,一般情况下高张盐溶液的钠含量为400~2400 mmol/L。目前临床及研究中常包括HSD (7.5% NaCl/6% dextran 70 solution), HS(7.5% NaCl solution)3.5%NaCl及11.2%NaCl等四种高张溶液,其中以前两者为多见[65-67]。荟萃分析研究表明休克复苏时HSD扩容效率优于HS和生理盐水,但是,对死亡率没有影响[68];一般认为,高张盐溶液通过使细胞内水进入循环而扩充容量 [69];有研究表明:在出血情况下,应用HSDHS可以改善心肌收缩力和扩张毛细血管前小动脉[70];其他有关其对微循环以及炎症反应等的影响的基础研究正在进行中,最近一项对于创伤失血性休克患者,高张盐溶液的免疫调理被初步证明[71]。对存在颅脑损伤的患者,有多项研究表明:由于可以很快升高平均动脉压而不加剧脑水肿,因此高张盐溶液可能有很好的前景,但是,目前尚缺乏大规模的循证医学证据[72-77]。一般认为,高张盐溶液主要的危险在于医源性高渗状态及高钠血症,甚至因此而引起的脱髓鞘病变,但多项研究这样的并发症发生率很低[72,75-76]

推荐意见12:没有足够循证医学证据证明高张盐水作为复苏液体选择有利于低血容量休克。 (E)

6.2.2.胶体液:目前有很多不同的胶体液可供选择,包括血浆、白蛋白、明胶、右旋糖苷和羟乙基淀粉。临床复苏治疗中应用的胶体液主要有羟乙基淀粉和白蛋白[78]

羟乙基淀粉是人工合成的胶体溶液, 主要由高分子量的支链淀粉组成,最常用为6 %的生理盐水溶液,其渗透压约为300moSM/L 。输注1L羟乙基淀粉能够使循环容量增加700~1000ml ,天然支链淀粉会被内源性的淀粉酶快速水解,而羟乙基化可以减缓这一过程,延长其在血管内的停留时间,使其扩容效应能维持4~8h。羟乙基淀粉在体内主要经肾清除,分子质量越小,取代级越低,其肾清除越快。有研究表明,HES平均分子质量越大,取代程度越高,在血管内的停留时间越长扩容强度越高,但是其对肾功能及凝血系统的影响也就越大[79-80]。在使用安全性方面,包括对肾功能的影响、对凝血的影响以及可能的过敏反应并且具有一定的剂量相关性[81-88]。最近,一项关于羟乙基淀粉溶液对肾功能的影响的研究表明,在ICU中应用羟乙基淀粉对患者的肾功能的影响没有显著差异,不增加应用血液净化的机率[89]。目前应用羟乙基淀粉对凝血的影响缺乏大规模的随机的研究,多项小规模研究表明:那些分子量小和取代级稍小,但C2/C6比率高的羟乙基淀粉可能对凝血影响小[90-93]

目前临床应用的人工胶体还包括:明胶和右旋糖苷,由于理化性质以及生理学特性不同,他们与羟乙基淀粉的扩容强度和维持时间略有不同,都可以达到容量复苏的目的,而在应用安全性方面,关注点是一致的。

推荐意见13:应用人工胶体进行复苏时,应注意不同人工胶体的安全性问题。(C级)

白蛋白是一种天然的血浆蛋白质,在正常人构成了血浆胶体渗透压的75 %~80 %,正常血清蛋白含96%的白蛋白,分子量约66000-69000。目前,人血清白蛋白有4%、5 %、10 %、20%和25 %几种浓度产品。每克白蛋白在血管内可与18毫升液体结合,输入2小时后只有不到10%的白蛋白移出血管,但是外源性白蛋白半衰期仅不到8小时[94]。作为最常用的非人工胶体,来源于人血,因此,应用时具有一些明确的不利之处,包括价格昂贵和理论上传播血源性疾病的风险[95]。目前,有关白蛋白的研究常见为等渗的白蛋白,缺乏不同渗透压的白蛋白的相关临床研究。

6.2.3.复苏治疗时液体的选择

胶体溶液和晶体溶液的主要区别在于,胶体溶液具有一定的胶体渗透压(COP)而两者分布容积明显不同。研究表明:应用不同晶体和胶体滴定复苏达到同样水平的充盈压时,它们恢复了同等程度的组织灌注[96]。多个荟萃分析表明,对于创伤、烧伤和手术后的患者,各种胶体溶液和晶体溶液复苏治疗并未显示对患者病死率的不同影响[97-100]。其中,有临床荟萃分析显示,尽管晶体液复苏所需的容量明显高于胶体液,两者对肺水肿发生率、住院时间和28d病死率均无显著差异[97]。现有的几种胶体溶液在物理化学性质、血浆半衰期等方面均有所不同,截止到目前,对于低血容量休克液体复苏时不同人工胶体溶液的选择尚缺乏大规模的相关临床研究。

临床上对于白蛋白的争论和相关研究也从来没有间断过,上个世纪末,一些研究甚至认为应用白蛋白增加死亡率[101];而之后的两项荟萃分析认为:应用白蛋白对于低白蛋白血症的患者有益,可以减少死亡率[102-3];2004年SAFE-study研究表明:白蛋白组和盐水组的机械通气时间和肾脏替代治疗时间均无显著性差异;28d病死率无统计学差异。对严重感染和急性呼吸窘迫综合征(ARDS)亚组进行进一步的分析,结果盐水和白蛋白组间也无明显差异。另外,在创伤亚组,应用白蛋白组的死亡率似乎有升高趋势。可见,白蛋白容量复苏是安全的,但复苏效果并不明显优于生理盐水。当然,研究也显示对于合并颅脑创伤的患者,白蛋白组的病死率明显低于生理盐水组[104]。与白蛋白相比,分子质量大的人工胶体溶液在血管内的停留时间长,扩容效应可能优于白蛋白,但目前尚缺乏人工胶体液与白蛋白或晶体液比较的大规模临床研究。

推荐意见14:低血容量休克液体复苏时选用晶体或胶体液同样有效。(B级)

6.2.4.液体复苏的速度

(1)静脉通路的重要性

低血容量休克时进行液体复苏刻不容缓,输液的速度应快到足以迅速补充丢失液体,以维持组织灌注。因此必须迅速建立至少两条大内径的快速外周静脉通路(14-16号),在紧急容量复苏时应该不首先选择放置中心静脉导管,肺动脉导管和中心静脉三腔导管的内径不足以进行容量复苏[94,105]

推荐意见15:为保证复苏速度,尽快建立有效静脉通路。(E)

(2) 容量负荷试验

容量负荷试验技术曾经以2,5毫米汞柱原则(应用中心静脉压)和3,7毫米汞柱原则(应用肺动脉契压)为基础进行容量复苏指导。目前改良的容量负荷试验技术包括以下四方面:1.液体的选择。2.输液速度的选择。3.时机和目标的选择。4.安全性限制。后两条可简单可归纳为反应性和耐受性,现在认为容量负荷试验的目的在于量化输液时的心血管反应,快速纠正容量缺失,尽可能减少容量过负荷的风险和可能的副反应尤其肺水肿,同时认为应该积极用于血流动力学不稳定的危重患者[106-7]。有人推荐:对septic shock患者选择1000ml 晶体溶液或500 ml胶体在30分钟内输入进行容量负荷试验,根据其结果指导其后的液体治疗[108],目前在其他危重情况时尚无明确推荐。

推荐意见16:复苏前可进行容量负荷试验以对输液速度及容量进行指导。(E级)

6.3输血治疗

输血及输注血制品在低血容量休克中应用广泛。输血也可能带来一些不良反应甚至严重并发症。失血性休克时,丧失的主要是血液,但是,补充血容量时,并不需要全部补充血液。关键是应抓紧时机及时进行容量复苏。

6.3.1浓缩红细胞:为保证组织的氧供,血红蛋白降至70g/L时应输血。对于有活动性出血的患者、老年人、以及有心梗风险的人,使血红蛋白保持在100g/L也是合理的[109]。没有活动性出血的患者每输注一个单位的浓缩红细胞其血红蛋白升高10g/L,血细胞压积升高3%。应该认识到,输血带来的不良反应,如传播疾病、凝血功能影响、免疫抑制,红细胞刚性增加,残留的白细胞分泌促炎和细胞毒性介质等。资料显示,输血量增加是导致患者不良预后的独立因素 [110]。所以临床必须对输血采取谨慎态度。目前临床一般制订的输血标准为70g/L。

6.3.2血小板:每50-70ml血小板液中含5.5X1010血小板 。血小板输注主要用于患者血小板数量减少或功能异常伴有出血倾向或表现。血小板计数>100 X109/L,可以不输注;血小板计数<50 X109/L,应考虑输注;血小板计数在50-100 X109/L之间,应根据是否有自发性出血或伤口渗血决定;如术中出现不可控渗血,确定血小板功能低下,输注血小板不受上述控制[111]。对大量输血后并发凝血异常的患者联合输注血小板和冷沉淀可显著改善止血效果[112]

6.3.3新鲜冰冻血浆:1U(250 ml)新鲜冰冻血浆含接近正常水平的所有凝血因子,包括400mg纤维蛋白原,能提高患者凝血因子水平约3%。近来的一些研究报道[113-4],大多数失血性休克患者在抢救过程中酸中毒和低体温度得到较好的调整后,凝血功能仍难以得到很好的纠正。应在早期积极改善凝血功能,早期复苏时红细胞与新鲜冰冻血浆的输注比例应为1:1[113,115-6]

6.3.4冷沉淀:内含凝血因子Ⅴ、Ⅷ、Ⅻ、纤维蛋白原等,适用于特定凝血因子缺乏所引起的疾病。对大量输血后并发凝血异常的患者及时输注冷沉淀可提高血循环中凝血因子及纤维蛋白原等凝血物质的含量,缩短凝血时间、纠正凝血异常[112,117]

6.3.5Hb代用品  Hb代用品是能运输和释放氧到组织的非细胞液,具有容易获得,无需配血,无病毒和细菌污染,无血液免疫抑制作用,保存时间长,粘度低等优点。Hb代用品近年发展较快,包括全氟化碳、来源于人和动物过期血的Hb及重组的Hb等。

推荐意见17:失血性休克患者血红蛋白低于70g/L,应考虑输血治疗。C级)

推荐意见18:重度失血性低血容量休克治疗的早期应注意积极纠正凝血功能的异常。(E级)

推荐意见19:复苏时红细胞与新鲜冰冻血浆的输注比例应为1:1。(C级)

6.4.血管活性药与正性肌力药

低血容量休克的患者,一般不常规使用用血管活性药,研究证实这些药物有进一步加重器官灌注不足和缺氧的风险[117-8]。通常临床仅在足够的液体复苏后仍存在低血压,或者输液还未开始的严重低血压患者,才考虑血管活性药与正性肌力药。

多巴胺:是一种中枢和外周神经递质,去甲肾上腺素的生物前体。它作用于三种受体:血管多巴胺受体、心脏β1受体和血管α受体[118-9]。1-3μg/kg/min主要作用于脑、肾、和肠系膜血管,使血管扩张,增加尿量[120]。2-10μg/kg/min时主要作用于β受体,通过增强心肌收缩能力而增加心输出量,同时也增加心肌氧耗。大于10μg/kg/min时以血管α受体兴奋为主,收缩血管[119]

多巴酚丁胺:多巴酚丁胺作为β1,β2-受体激动剂可使心肌收缩力增强,同时产生血管扩张和减少后负荷。有临床研究显示,尽管血压、心率和尿量正常,仍然有80-85%的患者存在组织低灌注,主要表现在乳酸增高和混合静脉血氧饱和度降低[120-1]。近期一项研究也显示在外科大手术后实施早期目标复苏中,有58%的患者ScvO2〈70%,输注了多巴酚丁胺,结果降低了术后并发症和缩短住院日[122]。低血容量休克充分液体复苏后仍然存在低心排,应使用多巴酚丁胺增加心排血量。若同时存在低血压可以考虑联合使用血管活性药。

去甲肾上腺素、肾上腺素和新福林,仅用于难治性休克,他们的主要效应是增加外周阻力来提高血压,同时也不同程度的收缩冠脉,可能加重心肌缺血[117]

推荐意见20:血管活性药少用于出血性休克,在容量补足、出血停止合并低血压持续存在时可选择使用。(E级)

推荐意见21:对创伤失血性低血容量休克患者实施早期目标治疗,可以改善预后(C级).

6.5.酸中毒

低容量休克时的有效循环量减少导致组织灌注不足,产生代谢性酸中毒,其严重程度与创伤的严重性及持续时间有关。一项前瞻性、多中心的研究显示BE增加明显与低血压、凝血时间、高创伤评分相关,BE的变化可以提示早期干预治疗的效果[123]。在对3791例创伤患者回顾性死亡因素分析,80%的患者有硷缺失,BE<-15mmol/L,死亡率达到25%[124]。研究乳酸水平与MODS及死亡率的相关性发现,乳酸水平24-48小时恢复正常其死亡率为25%,48小时未恢复正常的死亡率可达86%,早期持续高乳酸水平与创伤后发生MODS明显相关[45,125]

快速发生的代谢性酸中毒可能引起严重的低血压、心律失常和死亡[125]。临床上使用碳酸氢钠能短暂改善休克时的酸中毒,但是,不主张常规使用。研究表明,代谢性酸中毒的处理应着眼于病因处理、容量复苏等干预治疗,在组织灌注恢复过程中酸中毒状态可逐步纠正,过度的血液碱化使氧解离曲线左移,不利于组织供氧。因此失血性休克的治疗中碳酸氢盐的治疗只用于紧急情况或pH<7.15 [126]

推荐意见22:评估复苏满意的指标应关注碱缺失、乳酸水平(C级).

推荐意见23:纠正代谢性酸中毒应注意原发因素的处理,不主张常规使用碳酸氢钠(B级)。

6.6.肠粘膜屏障功能的保护:失血性休克时,肠道低灌注、缺血缺氧发生得最早、最严重。肠黏膜屏障功能迅速减弱,肠腔内细菌或内毒素向肠腔外转移机会增加。此过程即细菌移位或内毒素移位,该过程在复苏后仍可持续存在。近年来,人们认为肠道是外科应急条件下的中心器官,肠道的缺血再灌注损伤是休克创伤病理生理发展的共同通路。保护肠黏膜屏障功能,减少细菌与毒素移位,已成为低血容量休克治疗和研究工作重要内容[127-129]

推荐意见24:低血容量休克复苏要注意肠黏膜屏障功能的保护(E级)

6.7.体温控制

严重低血容量休克常伴有顽固性低体温、严重酸中毒、凝血障碍。失血性休克合并低体温是一种疾病严重的临床征象,回顾性研究显示低体温往往伴随更多的血液丢失和更高的病死率[130]。低体温(<35℃)可影响血小板的功能、降低凝血因子的活性、影响纤维蛋白的形成[131-3]。低体温增加创伤患者严重出血的危险性,是出血和病死率增加的独立危险因素[134]。但是,在合并颅脑损伤的患者控制性降温和正常体温相比显示出一定的积极效果,2003年一项荟萃研究显示对颅脑损伤的患者可降低病死率,促进神经功能的恢复[135-6]。2004年的另一个荟萃分析显示不降低病死率,但对神经功能的恢复有益[137]。能从控制性降温中获益的是那些入院GCS评分在4-7分的患者。应在外伤后3小时内开始实施,并维持48小时[138]

推荐意见25:严重低血容量休克伴低体温的患者应维持正常体温。(C级)

推荐意见26:入院GCS评分在4-7分的低血容量休克患者3小时内开始控制性降温。(C级)

7.复苏终点与预后评估指标

7.1.临床指标

传统复苏目标为患者的心率(<120次/分)、血压(平均动脉压>60mmHg)、神志改善和尿量(>0.5ml/hr/kg),有报道高达50%~85%达到传统指标后的低血容量休克患者仍然存在组织低灌注,这种状态的持续最终可能导致患者死亡[139, 140]

推荐意见27:传统临床指标对于指导低血容量休克治疗有一定的临床意义,但是不能作为复苏的终点目标(D级)。

7.2.氧输送与氧消耗

人们曾把心指数>4.5L/(min·m2)、氧输送>600 ml/(min·m2)及氧消耗>170 ml/(min·m2)作为包括低血容量休克在内的创伤高危患者的复苏目标[141]。研究[25,142]结果证明该指标并不能够降低创伤患者的病死率。研究[25,142]发现复苏后达到超正常氧输送标的创伤患者生存率较无达标的患者无明显改善,但是,开始复苏时已达到上述指标的患者生存率明显上升。而因,此该指标似乎可作为一个预测预后的指标,而非复苏终点目标。DO2和VO2都是二级参数,需通过肺动脉导管获得原始参数,属侵入性操作,对操作技术的要求也限制了其应用。

推荐意见28:对于低血容量休克,氧动力学参数作为复苏终点目标的证据不足。(E级)

推荐意见29:氧动力学参数可作为一个较好的预后评估指标。(C级)

7.3.混合静脉氧饱和度(SvO2)

SvO2的变化可反映全身氧摄取,在理论上能表达氧供和氧摄取的平衡状态。River以此作为感染性休克复苏的指标,使死亡率明显下降[1]。但缺乏在低血容量休克中研究的证据,至今还缺少与乳酸、DO2和胃粘膜pH作为复苏终点的比较资料。

7.4.血乳酸(BL)

正常值为1~2mmol/L。以BL清除率正常化作为复苏终点优于MAP和尿量,也优于以DO2、VO2和CI作为复苏终点[44]。以达到血乳酸浓度正常(≤2mmol/L)为标准,有人称复苏的第一个24小时为“银天”(silver day)[144], 在此时间内患者的血乳酸降至正常,患者的存活率为100%。血乳酸的水平与低血容量休克患者的预后密切相关,持续高水平的血乳酸(>4mmol/L)预示患者的预后不佳[43,145]。血乳酸清除率比单纯的血乳酸值能更好的反映患者的预后[37]

推荐意见30:动脉血乳酸浓度原始水平及恢复正常的时间与预后密切相关,复苏时应在24小时内将血乳酸降至正常水平。(C)

7.5.碱缺失 

碱缺失可反映全身组织酸中毒的程度。碱缺失可分为三度[146]:轻度(-2~-5mmol/l),中度(-6~-14 mmol/l),重度(≤-15 mmol/l)。重度(<-15) ,其与创伤后头24小时晶体和血液补充量相关.碱缺失加重与进行性出血大多有关。碱缺失增加而似乎平稳的患者需细心检查有否进行性出血。碱缺失与患者的预后密切相关,多项研究[123,124,126,147-8]其中包括一项前瞻性、多中心的研究[123]发现:碱缺失的值越低, MODS发生率、死亡率和凝血障碍的机率越高,住院时间越长。

推荐意见31:碱缺失的水平与预后密切相关,在复苏时应持续监测(B)。

推荐意见32:目前无资料显示碱缺失可作为复苏终点目标(E)。

 

7.6. 胃粘膜内pH(pHi)和胃粘膜内CO2分压(PgCO2)

pHi反映内脏或局部组织的灌流状态,对休克具有早期预警意义,与低血容量休克患者的预后具有相关性[149-151]。已有研究证实PgCO2比pHi更可靠[152]。当胃粘膜缺血时,PgCO2大于PaCO2,P(g-a)CO2差别大小与缺血程度有关[153]。PgCO2正常值小于6.5kPa, P(g-a)CO2<1.5kPa, PgCO2或P(g-a)CO2值越大,表示缺血越严重。pHi复苏到>7.30作为终点并且<24小时达到这一终点与超正常氧输送为终点的复苏效果类似,但是比氧输送能更早、更精确的预测患者的死亡和MODS的发生[154]。然而,最近研究发现胃粘膜张力计指导下的常规治疗和在胃粘膜张力计指导下的最大程度改善低灌注和再灌注损伤的治疗,结果发现患者的病死率、MODS发生率、机械通气时间和住院天数的差异并没有显著统计学意义[155]

推荐意见33:pHi可以用于评估预后。目前无临床循证医学证据支持pHi可以指导休克复苏。(C)

 

7.7.其他

皮肤、皮下组织和肌肉血管床可用来更直接地测定局部细胞水平的灌注。经皮或皮下氧张力测定、近红外线光谱分析及应用光导纤维测定氧张力测定等新技术已将复苏终点推进到细胞和亚细胞水平。但缺乏快速准确的评价结果及大规模的临床验证。

8.未控制出血的失血性休克复苏

未控制出血的失血性休克是低血容量休克的一种特殊类型,常见于严重创伤(贯通伤、血管伤、实质性脏器损伤、长骨和骨盆骨折、胸部创伤、腹膜后血肿等)、消化道出血、妇产科出血等。未控制出血的失血性休克患者死亡的原因主要是大量出血导致严重持续的低血容量休克甚至心跳骤停[156]

近年的大量基础研究证实,失血性休克未控制出血时早期积极复苏可引起稀释性凝血功能障碍;血压升高后,血管内已形成的栓塞凝血块脱落,造成再出血;血液过度稀释,血红蛋白降低,减少组织氧供;并发症和病死率增加。因此提出了限制性液体复苏,即在活动性出血控制前应给予小容量液体复苏,在短期允许的低血压范围内维持重要脏器的灌注和氧供,避免早期积极复苏带来的副作用[157]。动物试验表明限制性液体复苏可降低死亡率、减少再出血量及并发症[27,158-163]

有研究比较了即刻复苏和延迟复苏对躯体贯通伤的创伤低血压患者(收缩压<90mmHg)死亡率和并发症的影响,即刻复苏组死亡率显著增高,急性呼吸窘迫综合征、急性肾衰、凝血障碍、严重感染等的发生率也明显增高[164]。回顾性临床研究表明未控制出血的失血性休克患者现场就地早期复苏病死率明显高于到达医院延迟复苏的患者[164]。另一项临床研究也发现活动性出血早期复苏时将收缩压维持在70或100mmHg并不影响患者的病死率,其结果无差异可能与患者病例数少、病种(钝挫伤49%、穿透伤51%)、病情严重程度轻和研究中的方法学有关,其限制性复苏组的平均收缩压也达到了100mmHg[166]。另外,大量的晶体复苏还增加继发性腹腔间隔综合征的发病率[167-8]。对于非创伤性未控制出血的失血性休克,有研究显示在消化道出血的失血性休克患者,早期输血组再出血率明显增加[169]。但早期限制性液体复苏是否适合各类失血性休克,需维持多高的血压,可持续多长时间尚未有明确的结论。

对于颅脑损伤患者,合适的灌注压是保证中枢神经组织氧供的关键。颅脑损伤后颅内压增高,此时若机体血压降低,则会因脑血流灌注不足而继发脑组织缺血性损害,进一步加重颅脑损伤。因此,一般认为对于合并颅脑损伤的严重失血性休克患者,宜早期输液以维持血压,必要时合用血管活性药物,将收缩压维持在正常水平,以保证颅内灌注压,而不宜延迟复苏[170-1]。允许性低血压在老年患者应谨慎使用,在有高血压病史的患者也应视为禁忌。

推荐意见34:对未控制出血的贯通伤失血性休克患者,早期采用延迟复苏,收缩压维持在80~90mmHg,保证重要脏器的灌注,并及时止血。出血控制后再进行积极容量复苏。(推荐级别:D级)

推荐意见35:对合并颅脑损伤的多发伤患者、老年患者及高血压患者应避免延迟复苏。(推荐级别:E级)

——-来自网络

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