每日一题_2022.06.15

A 57-year-old man presents to the emergency department in septic shock. Abdominal CT reveals cecal volvulus and perforation. The intensivist initiates appropriate antimicrobial coverage, obtains adequate venous access, and orders cultures and laboratory testing. The patient is scheduled for emergent surgical intervention to obtain source control. The intensivist then initiates aggressive resuscitation for the patient’s wide-gap metabolic acidosis. The patient initially receives a two-liter bolus of normal saline (NS). His lactate remains elevated on an interval check, and the bedside nurse asks the intensivist what type of resuscitative fluid should be used at that point. Compared to low-chloride resuscitative fluids (ie, balanced saline solutions), the use of high-chloride resuscitative fluids (ie, NS) for septic patients requiring abdominal surgery is associated with?

A. a higher rate of in-hospital mortality 

B. a higher rate of metabolic alkalosis 

C. a lower rate of acute kidney injury

D. fewer blood product transfusions

E. fewer postoperative course infections

答案解析：

不幸的是，没有理想的复苏液体；所有复苏液体作为肠外药物都有一定的生理影响。生理盐水被指定为“正常”是基于19世纪错误地计算血液中的盐浓度为0.9%（血液的实际盐浓度接近0.6%）（原来生理盐水不生理）。盐水经常通过大容量复苏引起高氯性代谢性酸中毒。虽然这是一种一过性效应，但酸中毒与免疫抑制和凝血病相关。还发现生理盐水与肾损伤相关；在人类和动物模型中，数据表明氯化物负荷增加降低了肾脏灌注，并可能干扰肾脏止血。高氯化物负荷也与肾脏替代治疗需求增加相关。观察脓毒症患者和腹部手术患者的个体研究显示，在高氯化物复苏策略中，全因住院死亡率增加。

正确答案：A