每日一题_2022.08.09

A 19-year-old, 90-kg(198-lb) man sustains a grade IV splenic laceration in a motor vehicle collision. Because of hemodynamic instability, he undergoes damage control laparotomy. He is transferred to the ICU for ongoing resuscitation. Vital signs on arrival include blood pressure 80/40 mm Hg and heart rate 125 beats/min. Urine output is 15 mL/hour. After resuscitation with crystalloid and blood products, blood pressure is 117/75 mm Hg, heart rate 99 beats/min, and urine output 100 mL/hour. Lactate level is 5.2 mmol/L, and base deficit is -9 mmol/L.

Which of the following is the most appropriate course of action at this time?

A. Further aggressive resuscitation should be withheld.

B. His base deficit should be corrected with the administration of sodium bicarbonate.

C. Aggressive fluid resuscitation should be continued.

D. A pulmonary artery catheter should be placed to better define his hemodynamics and titrate his resuscitation.

答案解析：

创伤复苏的最佳终点尚不清楚。尿量和生命体征恢复正常是一个很好的迹象，但已知的是，如果复苏停止，相当大比例的患者将被留在复苏不足（隐休克），并有多器官衰竭和死亡的风险。最谨慎的策略是将整个临床表现与多种低灌注标志物相结合，包括生命体征、体格检查、尿量、乳酸盐、碱缺失、混合静脉血氧饱和度等，同时权衡正在进行的液体和产品给药的风险-获益分析（例如，氧合恶化或腹腔间隔室综合征的可能性）。在创伤人群中研究了碱缺失，与结局相关。但是，该数据不稳健，无法报告任何置信度的特定阈值水平或校正时间范围。此外，碱缺失是低灌注的粗标志物，可受到治疗（如氯化物给药）的高度影响。肺动脉导管在该患者中无明确作用。

个人其实答案不好，是否进一步液体复苏，取决于容量现在的状态是否已经合适了，需要有有创或者无创来评估，包括乳酸是否下降等。

正确答案：C