Hydroxyethyl starch for perioperative goal-directed fluid therapy in 2020: a narrative review
Joosten A, Coeckelenbergh S, Alexander B, et al. Hydroxyethyl starch for perioperative goal-directed fluid therapy in 2020: a narrative review. BMC Anesthesiol. 2020;20(1):209. Published 2020 Aug 20. doi:10.1186/s12871-020-01128-1Abstract
Background: Perioperative fluid management - including the type, dose, and timing of administration -directly affects patient outcome after major surgery. The objective of fluid administration is to optimize intravascular fluid status to maintain adequate tissue perfusion. There is continuing controversy around the perioperative use of crystalloid versus colloid fluids. Unfortunately, the importance of fluid volume, which significantly influences the benefit-to-risk ratio of each chosen solution, has often been overlooked in this debate.Main text: The volume of fluid administered during the perioperative period can influence the incidence and severity of postoperative complications. Regrettably, there is still huge variability in fluid administration practices, both intra-and inter-individual, among clinicians. Goal-directed fluid therapy (GDFT), aimed at optimizing flow-related variables, has been demonstrated to have some clinical benefit and has been recommended by multiple professional societies. However, this approach has failed to achieve widespread adoption. A closed-loop fluid administration system designed to assist anesthesia providers in consistently applying GDFT strategies has recently been developed and tested. Such an approach may change the crystalloid versus colloid debate. Because colloid solutions have a more profound effect on intravascular volume and longer plasma persistence, their use in this more "controlled" context could be associated with a lower fluid balance, and potentially improved patient outcome. Additionally, most studies that have assessed the impact of a GDFT strategy on the outcome of high-risk surgical patients have used hydroxyethyl starch (HES) solutions in their protocols. Some of these studies have demonstrated beneficial effects, while none of them has reported severe complications.Conclusions: The type and volume of fluid used for perioperative management need to be individualized according to the patient's hemodynamic status and clinical condition. The amount of fluid given should be guided by well-defined physiologic targets. Compliance with a predefined hemodynamic protocol may be optimized by using a computerized system. The type of fluid should also be individualized, as should any drug therapy, with careful consideration of timing and dose. It is our perspective that HES solutions remain a valid option for fluid therapy in the perioperative context because of their effects on blood volume and their reasonable benefit/risk profile.Keywords: Acute renal failure; Balanced crystalloids; Colloid; Fluid responsiveness; Hemodynamic monitoring; Outcome.2020年羟乙基淀粉在围手术期目标导向液体治疗中的应用：一项叙述性综述摘要
背景：围手术期液体管理-包括给药类型、剂量和时间-直接影响大手术后患者的预后。液体管理的目的是优化血管内液体状态，以维持足够的组织灌注。关于围手术期使用晶体液还是胶体液仍存在争议。不幸的是，在这场辩论中，流体体积的重要性常常被忽视，它会显著地影响每一种选择的解决方案的效益与风险比。
围手术期输液量会影响术后并发症的发生率和严重程度。遗憾的是，无论是个体内还是个体间，临床医生的液体给药方式仍然存在巨大的差异。目标导向液体疗法（GDFT）旨在优化血流相关变量，已被证明具有一定的临床效益，并被多个专业协会推荐。然而，这种方法未能得到广泛采用。最近开发并测试了一种闭环液体给药系统，以协助麻醉提供者持续应用GDFT策略。这种方法可能会改变晶体与胶体的争论。由于胶体溶液对血管内容量和血浆持续时间有更深远的影响，因此在这种更“受控”的情况下使用胶体溶液可能会降低液体平衡，并可能改善患者的预后。此外，大多数研究已经评估了GDFT策略对高危外科患者预后的影响，在他们的研究方案中使用了羟乙基淀粉（HES）溶液。这些研究中的一些已经证明了有益的效果，但是没有一个报告有严重的并发症。
结论：围手术期处理所用液体的种类和体积需要根据患者的血流动力学状况和临床情况进行个体化。给药量应以明确的生理指标为指导。使用计算机系统可以优化对预先确定的血液动力学协议的遵从性。液体的类型也应该是个性化的，就像任何药物治疗一样，要仔细考虑时间和剂量。我们的观点是，HES解决方案仍然是围手术期液体治疗的有效选择，因为它们对血容量的影响及其合理的效益/风险状况。
关键词：急性肾功能衰竭；平衡晶体；胶体；液体反应性；血流动力学监测；预后。
转载来源：CME麻醉论坛
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