{"id":22090,"date":"2022-06-27T05:08:00","date_gmt":"2022-06-26T21:08:00","guid":{"rendered":"http:\/\/csccm.org.cn\/?p=22090"},"modified":"2022-06-27T05:43:56","modified_gmt":"2022-06-26T21:43:56","slug":"nejm%e5%8c%bb%e5%ad%a6%e5%89%8d%e6%b2%bf%ef%bc%9aclassic%e7%a0%94%e7%a9%b6%e8%bf%b0%e8%af%84%ef%bf%bc","status":"publish","type":"post","link":"https:\/\/csccm.org.cn\/?p=22090","title":{"rendered":"[NEJM\u533b\u5b66\u524d\u6cbf]\uff1aCLASSIC\u7814\u7a76\u8ff0\u8bc4\ufffc"},"content":{"rendered":"\n

\u4f20\u7edf\u89c2\u70b9\u8ba4\u4e3a\uff0c\u7531\u4e8e\u6db2\u4f53\u4e22\u5931\u548c\u8840\u7ba1\u6269\u5f20\uff0c\u611f\u67d3\u6027\u4f11\u514b\u60a3\u8005\u53ef\u51fa\u73b0\u5faa\u73af\u5bb9\u91cf\u7684\u7edd\u5bf9\u548c\u76f8\u5bf9\u4e0d\u8db3\uff0c\u56e0\u6b64\uff0c\u79ef\u6781\u7684\u6db2\u4f53\u590d\u82cf\u662f\u7ea0\u6b63\u5faa\u73af\u529f\u80fd\u969c\u788d\u548c\uff08\u6216\uff09\u7ec4\u7ec7\u4f4e\u704c\u6ce8\u7684\u91cd\u8981\u624b\u6bb5[1]\u3002\u7136\u800c\uff0c\u8fd1\u5e74\u6765\u7684\u7814\u7a76\u63d0\u793a\uff0c\u6db2\u4f53\u6b63\u5e73\u8861\u6216\u5bb9\u91cf\u8d1f\u8377\u8fc7\u591a\u662f\u5305\u62ec\u611f\u67d3\u6027\u4f11\u514b\u5728\u5185\u7684\u91cd\u75c7\u60a3\u8005\u4e0d\u826f\u9884\u540e\u751a\u81f3\u6b7b\u4ea1\u7684\u72ec\u7acb\u5371\u9669\u56e0\u7d20[2]\u3002\u57fa\u4e8e\u8fd9\u4e9b\u53d1\u73b0\uff0c\u9650\u5236\u6027\u6db2\u4f53\uff08\u590d\u82cf\uff09\u6cbb\u7597\u6210\u4e3a\u611f\u67d3\u6027\u4f11\u514b\u4e34\u5e8a\u7814\u7a76\u7684\u70ed\u70b9\u95ee\u9898\u3002<\/p>\n\n\n\n

\u521a\u521a\u5728\u7ebf\u53d1\u8868\u7684CLASSIC\u7814\u7a76\u65e8\u5728\u8bc4\u4ef7\u9650\u5236\u9759\u8109\u6db2\u4f53\u5bf9ICU\u4e2d\u611f\u67d3\u6027\u4f11\u514b\u60a3\u8005\u7684\u75c5\u6b7b\u7387\u53ca\u5176\u4ed6\u91cd\u8981\u9884\u540e\u6307\u6807\u7684\u5f71\u54cd[3]\u3002\u8fd9\u662f\u4e00\u9879\u524d\u77bb\u968f\u673a\u5bf9\u7167\u8bd5\u9a8c\uff0c\u57288\u4e2a\u56fd\u5bb6\u768431\u4e2aICU\u8fdb\u884c\u3002\u7814\u7a76\u5165\u9009\u4e861554\u540d\u6210\u5e74\u611f\u67d3\u6027\u4f11\u514b\u60a3\u8005\uff0c\u5165\u9009\u65f6\u8ddd\u79bb\u4f11\u514b\u53d1\u751f\u4e0d\u8d85\u8fc712\u5c0f\u65f6\uff0c\u4e14\u65e2\u5f8024\u5c0f\u65f6\u5185\u81f3\u5c11\u8f93\u6ce81 L\u7684\u9759\u8109\u6db2\u4f53\u3002\u6309\u71671:1\u7684\u6bd4\u4f8b\u5c06\u5165\u9009\u60a3\u8005\u968f\u673a\u5206\u4e3a\u9650\u5236\u9759\u8109\u6db2\u4f53\u7ec4\u4e0e\u6807\u51c6\u9759\u8109\u6db2\u4f53\u7ec4\u3002\u9650\u5236\u9759\u8109\u6db2\u4f53\u7ec4\u60a3\u8005\u4ec5\u5728\u4ee5\u4e0b\u56db\u79cd\u60c5\u51b5\u4e0b\u63a5\u53d7\u9759\u8109\u8f93\u6db2\uff1a\u4e25\u91cd\u4f4e\u704c\u6ce8\uff0c\u8865\u5145\u5df2\u77e5\u6db2\u4f53\u4e22\u5931\uff0c\u7ea0\u6b63\u8131\u6c34\uff0c\u4ee5\u53ca\u65e0\u6cd5\u4f7f\u7528\u80a0\u9053\u65f6\u4fdd\u8bc1\u6bcf\u65e5\u6db2\u4f53\u6444\u5165\u91cf\uff1b\u800c\u6807\u51c6\u9759\u8109\u6db2\u4f53\u7ec4\u60a3\u8005\u5219\u6ca1\u6709\u4e0a\u8ff0\u9650\u5236\u3002<\/p>\n\n\n\n

\u7814\u7a76\u53d1\u73b0\uff0c\u968f\u673a\u5206\u7ec4\u540e24\u5c0f\u65f6\u5185\uff0c\u9650\u5236\u9759\u8109\u6db2\u4f53\u7ec4\u6db2\u4f53\u5165\u91cf(1843 vs. 2708 ml)\u4e0e\u9759\u8109\u8f93\u6db2\u91cf(500 vs. 1313 ml)\u5747\u660e\u663e\u5c11\u4e8e\u6807\u51c6\u9759\u8109\u6db2\u4f53\u7ec4\u3002\u5728ICU\u4f4f\u9662\u671f\u95f4\uff0c\u4e24\u7ec4\u60a3\u8005\u9759\u8109\u6db2\u4f53\u5165\u91cf\u5206\u522b\u4e3a1798 ml\u548c3811 ml\u3002\u4e24\u7ec4\u60a3\u800590\u5929\u5168\u56e0\u75c5\u6b7b\u7387\u65e0\u663e\u8457\u5dee\u5f02(42.3% vs. 42.1%)\uff0c\u4e25\u91cd\u4e0d\u826f\u4e8b\u4ef6\u53d1\u751f\u7387\u76f8\u4f3c(29.4% vs. 30.8%)\uff0c\u4e14\u65e0\u751f\u547d\u652f\u6301\u6cbb\u7597\u5929\u6570\u548c\u975e\u4f4f\u9662\u5929\u6570\u4e5f\u65e0\u7edf\u8ba1\u5b66\u5dee\u5f02\u3002<\/p>\n\n\n\n

\"\"\/<\/figure>\n\n\n\n

\u5e94\u5f53\u5982\u4f55\u89e3\u8bfb\u8fd9\u4e00\u7814\u7a76\u7ed3\u679c\u5462\uff1f<\/p>\n\n\n\n

\u9996\u5148\uff0c\u7814\u7a76\u65e8\u5728\u5165\u9009\u611f\u67d3\u6027\u4f11\u514b\u65e9\u671f\u60a3\u8005\uff0c\u56e0\u6b64\uff0c\u7814\u7a76\u65b9\u6848\u8981\u6c42\u60a3\u8005\u5165\u9009\u65f6\u8ddd\u79bb\u4f11\u514b\u53d1\u751f\u65f6\u95f4\u4e0d\u5f97\u8d85\u8fc712\u5c0f\u65f6\u3002\u7ed3\u679c\u663e\u793a\uff0c\u60a3\u8005\u5165\u9662\u5230\u968f\u673a\u5206\u7ec4\u7684\u4e2d\u4f4d\u65f6\u95f4\u4e3a1\u5929\uff0c\u4ece\u6536\u5165ICU\u5230\u968f\u673a\u5206\u7ec4\u7684\u4e2d\u4f4d\u65f6\u95f4\u4e3a3\u5c0f\u65f6[3]\u3002\u7136\u800c\uff0c\u9700\u8981\u6ce8\u610f\u7684\u662f\uff0c\u5728\u968f\u673a\u5206\u7ec4\u540e\u7b2c\u4e00\u4e2a24\u5c0f\u65f6\u5185\uff0c\u6807\u51c6\u9759\u8109\u6db2\u4f53\u7ec4\u60a3\u8005\u7684\u6db2\u4f53\u603b\u5165\u91cf\u4e2d\u4f4d\u6570\u4ec5\u4e3a2708 ml\uff08\u5176\u4e2d\u9759\u8109\u6db2\u4f53\u5165\u91cf1313 ml\uff09\uff0c\u751a\u81f3\u5c11\u4e8e\u5165\u9009\u524d\u4e00\u5929\u7684\u6db2\u4f53\u5165\u91cf(3000 ml)\uff0c\u800c\u9650\u5236\u9759\u8109\u6db2\u4f53\u7ec4\u7684\u5dee\u5f02\u66f4\u4e3a\u663e\u8457(1843 ml vs. 3200 ml)\u3002<\/p>\n\n\n\n

\u4e3a\u4f55\u60a3\u8005\u5728\u53d1\u751f\u611f\u67d3\u6027\u4f11\u514b\u540e\u9700\u8981\u7684\u8f93\u6db2\u91cf\u4e0d\u5347\u53cd\u964d\uff1f\u4ece\u4e34\u5e8a\u89d2\u5ea6\u5206\u6790\uff0c\u65e0\u5916\u4e4e\u4ee5\u4e0b\u51e0\u79cd\u60c5\u51b5\uff1a1)\u4f4e\u8840\u5bb9\u91cf\u5df2\u57fa\u672c\u5f97\u5230\u7ea0\u6b63\uff1b2)\u5408\u5e76\u4e25\u91cd\u7684\u91cd\u8981\u5668\u5b98\uff08\u8111\u6216\u80ba\uff09\u6c34\u80bf\uff1b3)\u5408\u5e76\u660e\u663e\u7684\u5fc3\u529f\u80fd\u969c\u788d\u3002\u9057\u61be\u7684\u662f\uff0c\u6839\u636e\u6587\u7ae0\u62a5\u544a\u7684\u6570\u636e\uff0c\u6211\u4eec\u96be\u4ee5\u5bf9\u4e0a\u8ff0\u51e0\u79cd\u60c5\u51b5\u8fdb\u884c\u5224\u65ad\u3002\u4f46\u662f\uff0c\u5728\u6574\u4e2aICU\u4f4f\u9662\u671f\u95f4\uff0c\u4e24\u7ec4\u60a3\u8005\u7528\u4e8e\u7ea0\u6b63\u7ec4\u7ec7\u4f4e\u704c\u6ce8\u6216\u8865\u5145\u6db2\u4f53\u4e22\u5931\u7684\u9759\u8109\u8f93\u6db2\u91cf\u5f88\u5c11\uff08\u9650\u5236\u9759\u8109\u6db2\u4f53\u7ec4\u918b\u9178\u6797\u683c\u6db2\u5165\u91cf\u4e2d\u4f4d\u6570100 ml\uff0c\u6807\u51c6\u9759\u8109\u6db2\u4f53\u7ec4\u4e3a1000 ml\uff0c\u4e14\u4e24\u7ec4\u60a3\u8005\u5176\u4ed6\u6676\u4f53\u6db2\u5165\u91cf\u4e2d\u4f4d\u6570\u5747\u4e3a0 ml\uff09\uff0c\u63d0\u793a\u5927\u591a\u6570\u5165\u9009\u60a3\u8005\u4e0d\u5b58\u5728\u4e25\u91cd\u7684\u4f4e\u8840\u5bb9\u91cf\uff0c\u56e0\u6b64\u5e76\u4e0d\u9700\u8981\u63a5\u53d7\u79ef\u6781\u7684\u6db2\u4f53\u590d\u82cf\u3002<\/p>\n\n\n\n

\u5176\u6b21\uff0c\u5bf9\u4e8e\u65e9\u671f\u611f\u67d3\u6027\u4f11\u514b\u60a3\u8005\uff0c\u901a\u8fc7\u4f7f\u7528\u5c0f\u5242\u91cf\u5347\u538b\u836f\u7269\u6536\u7f29\u5bb9\u91cf\u8840\u7ba1\uff0c\u5b9e\u65bd\u9650\u5236\u6027\u6db2\u4f53\u590d\u82cf\uff0c\u4e5f\u80fd\u591f\u7ef4\u6301\u5145\u5206\u7684\u7ec4\u7ec7\u704c\u6ce8\u53ca\u5668\u5b98\u529f\u80fd[4]\u3002\u7136\u800c\uff0cCLASSIC\u7814\u7a76\u5e76\u672a\u62a5\u544a\u4e24\u7ec4\u60a3\u8005\u5347\u538b\u836f\u7269\u5242\u91cf\u4ee5\u53ca\u7ec4\u7ec7\u704c\u6ce8\u6307\u6807\u968f\u65f6\u95f4\u7684\u53d8\u5316\u3002\u5982\u679c\u9650\u5236\u9759\u8109\u6db2\u4f53\u7ec4\u60a3\u8005\u5347\u538b\u836f\u7269\u5242\u91cf\u4e0e\u6807\u51c6\u9759\u8109\u6db2\u4f53\u7ec4\u5e76\u65e0\u5dee\u5f02\uff0c\u5219\u8bf4\u660e\u6240\u8c13\u6807\u51c6\u9759\u8109\u6db2\u4f53\u7ec4\u60a3\u8005\u5b9e\u9645\u4e0a\u63a5\u53d7\u4e86\u4e0d\u5fc5\u8981\u7684\u6db2\u4f53\u6cbb\u7597\uff1b\u5982\u679c\u9650\u5236\u9759\u8109\u6db2\u4f53\u7ec4\u60a3\u8005\u4f7f\u7528\u4e86\u66f4\u5927\u5242\u91cf\u7684\u5347\u538b\u836f\u7269\uff0c\u5219\u63d0\u793a\u901a\u8fc7\u4f7f\u7528\u5c0f\u5242\u91cf\u5347\u538b\u836f\u7269\u5b9e\u65bd\u9650\u5236\u6027\u6db2\u4f53\u6cbb\u7597\u4e0e\u6807\u51c6\u6db2\u4f53\u6cbb\u7597\u5b9e\u8d28\u4e0a\u662f\u7b49\u6548\u7684\uff0c\u5b9e\u9645\u5de5\u4f5c\u4e2d\u5e94\u5f53\u6743\u8861\u5347\u538b\u836f\u7269\u548c\u6db2\u4f53\u6cbb\u7597\u6240\u4f34\u968f\u7684\u98ce\u9669\u8fdb\u884c\u4e2a\u4f53\u5316\u7684\u9009\u62e9\u3002<\/p>\n\n\n\n

\u7b2c\u4e09\uff0c\u611f\u67d3\u6027\u4f11\u514b\u60a3\u8005\u9759\u8109\u8f93\u6db2\u6cbb\u7597\u7684\u7597\u6548\u4e0e\u6cbb\u7597\u5242\u91cf\u5bc6\u5207\u76f8\u5173\u3002\u56e0\u6b64\uff0c\u9650\u5236\u9759\u8109\u6db2\u4f53\u7ec4\u4e0e\u6807\u51c6\u9759\u8109\u6db2\u4f53\u7ec4\u9759\u8109\u6db2\u4f53\u5165\u91cf\u7684\u5dee\u5f02\u4e5f\u662f\u5f71\u54cd\u7814\u7a76\u7ed3\u679c\u7684\u5173\u952e\u56e0\u7d20\u3002\u7ed3\u679c\u663e\u793a[3]\uff0c\u4e24\u7ec4\u60a3\u8005\u5165\u7ec4\u540e\u7b2c\u4e00\u5929\u7684\u6db2\u4f53\u5165\u91cf\u76f8\u5dee865 ml\uff0c\u8fd9\u4e00\u5dee\u5f02\u4e3b\u8981\u6e90\u4e8e\u9759\u8109\u6db2\u4f53\u5165\u91cf\u7684\u5dee\u5f02(813 ml)\uff1b\u4e24\u7ec4\u60a3\u8005\u5165\u7ec4\u540e5\u5929\u7684\u7d2f\u79ef\u6db2\u4f53\u5165\u91cf\u76f8\u5dee1936 ml\uff0c\u5373\u5e73\u5747\u6bcf\u65e5\u76f8\u5dee\u4e0d\u8db3400 ml\u3002\u4e0e\u5355\u7eaf\u5165\u6db2\u91cf\u76f8\u6bd4\uff0c\u6db2\u4f53\u5e73\u8861\u5177\u6709\u66f4\u4e3a\u91cd\u8981\u7684\u4e34\u5e8a\u610f\u4e49\u3002\u5728\u5165\u7ec4\u540e\u7b2c1\u5929\uff0c\u7b2c5\u5929\u548c\u7b2c90\u5929\uff0c\u4e24\u7ec4\u60a3\u8005\u7684\u7d2f\u79ef\u6db2\u4f53\u5e73\u8861\u5206\u522b\u76f8\u5dee617 ml\uff0c744 ml\u548c723 ml\u3002\u5bf9\u4e8e\u5927\u591a\u6570\u611f\u67d3\u6027\u4f11\u514b\u60a3\u8005\u800c\u8a00\uff0c\u4e0a\u8ff0\u5dee\u5f02\u51e0\u4e4e\u4e0d\u4f1a\u5bf9\u4e34\u5e8a\u7ed3\u5c40\u9020\u6210\u4efb\u4f55\u5f71\u54cd\uff0c\u66f4\u4f55\u51b5\u8fd9\u79cd\u7a0b\u5ea6\u7684\u5dee\u5f02\u4e5f\u5728\u62a4\u7406\u75c5\u4f8b\u8bb0\u5f55\u6db2\u4f53\u5e73\u8861\u7684\u8bef\u5dee\u8303\u56f4\u5185[5]\u3002\u56e0\u6b64\uff0c\u4e24\u7ec4\u60a3\u8005\uff08\u9759\u8109\uff09\u6db2\u4f53\u5165\u91cf\u4ee5\u53ca\u6db2\u4f53\u5e73\u8861\u76f8\u5dee\u65e0\u51e0\uff0c\u96be\u4ee5\u6539\u53d8\u4e34\u5e8a\u7ed3\u5c40\u3002<\/p>\n\n\n\n

\u90a3\u4e48\uff0c\u4e0a\u8ff0\u7814\u7a76\u7ed3\u679c\u5bf9\u4e8e\u611f\u67d3\u6027\u4f11\u514b\u7684\u4e34\u5e8a\u6cbb\u7597\u6709\u4f55\u63d0\u793a\uff1f<\/p>\n\n\n\n

\u4e00\u65b9\u9762\uff0cCLASSIC\u7814\u7a76\u7ed3\u679c\u63d0\u793a\uff0c\u4e0e\u6807\u51c6\u9759\u8109\u8f93\u6db2\u6cbb\u7597\u76f8\u6bd4\uff0c\u9650\u5236\u9759\u8109\u6db2\u4f53\u4e0d\u80fd\u964d\u4f4e\u611f\u67d3\u6027\u4f11\u514b\u60a3\u8005\u768490\u5929\u5168\u56e0\u75c5\u6b7b\u7387\u3002\u53e6\u4e00\u65b9\u9762\uff0c\u611f\u67d3\u6027\u4f11\u514b\u60a3\u8005\u7684\u6db2\u4f53\u6b63\u5e73\u8861\u4e0e\u4e0d\u826f\u9884\u540e\u4e4b\u95f4\u66f4\u591a\u662f\u76f8\u5173\u5173\u7cfb(correlation)\u800c\u975e\u56e0\u679c\u5173\u7cfb(causal effect)\u3002\u6b64\u65f6\uff0c\u75be\u75c5\u4e25\u91cd\u7a0b\u5ea6\u662f\u4e00\u4e2a\u663e\u800c\u6613\u89c1\u7684\u6df7\u6742\u56e0\u7d20[6]\u3002\u56e0\u6b64\uff0c\u5f53\u60a3\u8005\u5b58\u5728\u660e\u663e\u7684\u4f4e\u8840\u5bb9\u91cf\u65f6\uff0c\u79ef\u6781\u7684\u6db2\u4f53\u590d\u82cf\u6cbb\u7597\u4ecd\u7136\u5341\u5206\u5173\u952e\u3002\u4e0d\u5e94\u76f2\u76ee\u8ffd\u6c42\u6db2\u4f53\u8d1f\u5e73\u8861\uff0c\u4ece\u800c\u5bfc\u81f4\u7ec4\u7ec7\u704c\u6ce8\u4e0d\u8db3\u3001\u5668\u5b98\u529f\u80fd\u969c\u788d\u751a\u81f3\u6b7b\u4ea1\u3002<\/p>\n\n\n\n

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  1. De Backer D, Cecconi M, Lipman J, et al. Challenges in the management of septic shock: a narrative review. Intensive Care Med 2019; 45: 420-433<\/li>
  2. Sakr Y, Birri PNR, Kotfis K, et al. Higher fluid balance increases the risk of death from sepsis: results from a large international audit. Crit Care Med 2017; 45: 386-394<\/li>
  3. Meyhoff TS, Hjortrup PB, Wetterslev J, et al. Restriction of intravenous fluid in ICU patients with septic shock. N Engl J Med 2022 epub ahead of print DOI: 10.1056\/NEJMoa2202707<\/li>
  4. Macdonald SPJ, Keijzers G, Taylor DM, et al. Restricted fluid resuscitation in suspected sepsis associated hypotension (REFRESH): a pilot randomizsed controlled trial. Intensive Care Med 2018; 44: 2070-2078<\/li>
  5. Perren A, Markmann M, Merlani G, et al. Fluid balance in critically ill patients. Should we really rely on it? Minerva Anestesiol 2011; 77: 802-811<\/li>
  6. Lederer DJ, Bell SC, Branson RD, et al. Control of confounding and reporting of results in casual inference studies: Guidance for authors from editors of respiratory, sleep, and critical care journals. Ann Am Thorac Soc 2019; 16: 283<\/li><\/ol>\n","protected":false},"excerpt":{"rendered":"

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