美国医院联合会人血白蛋白、非蛋白胶体及晶体溶液使用指南(中英对照)

AdaptedfromUHCGuidelinesfortheUseofAlbumin,NonproteinColloid,andCrystalloidSolutions,May2000.美国医院联合会人血白蛋白、非蛋白胶体及晶体溶液使用指南（2000年5月）HemorrhagicShockCrystalloidsshouldbeconsideredtheinitialresuscitationfluidofchoice.Nonproteincolloidsmaybeconsideredovercrystalloidswhencrystalloids(4L)havefailedtoproducearesponsewithin2hoursforadultpatients.Whennonproteincolloidsarecontraindicated*,albumin5percentmaybeused.Patientswhoexperienceshocksymptomswhileunder-goinghemodialysisareincludedinthisguideline.出血性休克晶体溶液可以作为首选药物用于扩张血容量。成人患者输入4L晶体液后2小时无效，可考虑非蛋白胶体液。当对非蛋白胶体液有禁忌，可以考虑使用5％白蛋白。在进行血液透析过程中出现休克表现，也符合如上处理原则。Nonhemorrhagic(Maldistributive)ShockCrystalloidsshouldbeconsideredfirst-linetherapyfornonhemorrhagicshock.Clinicaltrialshavenotshowncolloidstobemoreeffectiveintreatingsepsis.Inthepresenceofcapillaryleakwithpulmonaryand/orsevereperipheraledema,theadministrationofupto4Lofcrystalloidsinadultsbeforeusingcolloidsisappropriate.Ifnonproteincolloidsarecontraindicated*,albuminmaybegiven.Nonproteincolloidsandalbuminshouldbeusedwithcautioninpatientswithsystemicsepsis.非出血性（分布异常性）休克对于非出血性休克，晶体溶液可作为一线治疗药物。临床研究尚未证实胶体溶液用于治疗败血症更有效。发生毛细血管渗漏伴肺水肿或严重外周水肿时，使用胶体溶液之前，成人患者应先给予4L晶体溶液。如果非蛋白胶体溶液存在禁忌，给予白蛋白。对于败血症的患者，应慎用非蛋白胶体和白蛋白。ThermalInjuryFluidresuscitationshouldbeinitiatedwithcrystalloidsolutions.Ifcrystalloidresuscitationexceeds4Linadults18to26hourspostburn,andburnscovermorethan30percentofthepatient’sbodysurfacearea,nonproteincolloidsmaybeadded.Ifnonproteincolloidsarecontraindicated*,albuminmaybeused烧伤晶体溶液可作最初扩张血容量之用。成人患者烧伤后18-26小时内使用的晶体溶液已超过4L，烧伤面积大于体表面积的30%，加用非胶体溶液。如果非蛋白胶体溶液存在禁忌，给予白蛋白。CerebralPerfusionPressure(CPP)CrystalloidadministrationshouldbethefirstchoiceoftreatmentinmaintainingCPPfortreatmentofvasospasmassociatedwithsubarachnoidhemorrhage,cerebralischemia,orheadtrauma.Patientswithelevatedhematocritsshouldfirstreceivecrystalloidstoexpandintravascularvolume.Mannitolshouldbeusedtoreduceintracranialhypertension.Ifcerebraledemaisaconcern,albuminshouldbeusedinconcentratedform(25percent)asacolloidtomaintainCPP.Ifthehematocritislessthan30,usepackedredbloodcellstoincreasetheintravascularvolumeandmaintainCPP.Ifvolumetherapyaloneisineffective,vasopressorsmaybeneeded脑灌注压(CPP)对于蛛网膜下腔出血、缺血性中风和头部创伤引起的血管痉挛，应首选晶体溶液维持CPP。红细胞比容偏高的患者应首先用晶体溶液来扩张血容量。可应用甘露醇降低颅内压。如果存在脑水肿的危险，应使用高浓度白蛋白（25%）胶体液维持CPP。如果红细胞比容低于30，使用浓集红细胞扩张血容量和维持CPP。如扩容治疗无效，应使用血管收缩药。NutritionalInterventionAlbuminshouldnotbeusedasasupplementalsourceofproteincaloriesinpatientsrequiringnutritionalintervention.Patientswhocannottolerateenteralfeedingmaybenefitfromtheadministrationofnonproteincolloidsifallofthefollowingconditionsaremet:1.Serumalbuminlessthan2.0g/dL2.Functioninggastrointestinaltract3.Failedshort-chainpeptideformulas营养干预对于需要营养干预的患者，白蛋白不能作为蛋白质的补充来源。对于不能耐受肠道喂食的患者，如符合下列各条件，使用非蛋白胶体则可能获益：1.血清白蛋白浓度低于2.0g/dl2.严重腹泻（2L/d）3.使用短肽治疗无效CardiacSurgeryCrystalloidsshouldbethefluidofchoiceastheprimingsolutionforcardiopulmonarybypasspumps.Theuseofnonproteincolloidsinadditiontocrystalloidsmaybepreferableincasesinwhichitisextremelyimportanttoavoidpulmonaryshunting.Forpostoperativevolumeexpansion,crystalloidsshouldbeconsideredfirst-linetherapy,followedbynonproteincolloids,andfinallyalbumin.心脏手术晶体溶液应作为体外循环泵的首选溶液。亟须避免发生肺间质积液时，联合使用非蛋白胶体和晶体溶液效果更好。术后扩充血容量，首选晶体溶液，其次为非蛋白胶体，最后是白蛋白。HyperbilirubinemiaoftheNewbornAlbuminshouldnotbeadministeredinconjunctionwithphototherapy.Albuminmaybeausefuladjuvanttoexchangetransfusionswhenadministeredconcurrentlywithbloodtransfusionbutitshouldnotbeusedbeforetransfusion.Crystalloidsandnonproteincolloidsdonothavebilirubinbindingpropertiesandshouldnotbeconsideredasalternativestoalbumin.新生儿高胆红素血症白蛋白不能与光疗同时使用。输血时给予白蛋白，可作为换血疗法的辅助治疗，但输血之前不能使用。晶体溶液和非蛋白胶体不能胆红素结合，因此不能作为白蛋白的替代品。CirrhosisandParacentesisDietmodification(2gsodiumrestriction/day)inconjunctionwithdiuretictherapyshouldbefirst-linetherapyinadultpatientswhohavecirrhosiswithascites.Whenthesefailorarenottoleratedandlarge-volumeparacentesis(greaterthan5L)isneeded,albumin(25percent:6to8g/Lremoved)ornonproteincolloidsshouldbeconsideredthesolutionofchoice.Crystalloidsshouldbeconsideredasadjunctivetherapyinpatientswithcirrhosiswhenlessthan3Lareremovedandrepletionofintravascularvolumeisofconcern.Usingalbuminalonetotreatasciteswithoutlarge-volumeparacentesisortotreatpatientswithnoncirrhoticpostsinusoidalportalhypertensionshouldbeavoided.肝硬化和穿刺术肝硬化腹水的成人患者，首选饮食调节（每日限钠2g）联合利尿治疗。当上述治疗失败或不能耐受，或大量（5L）腹水需行穿刺术时，可给予白蛋白（25%：每抽取1升腹水补充6-8g白蛋白）或非蛋白胶体溶液。抽取腹水量3L并且需要扩充血容量的肝硬化患者，晶体溶液可作为联合治疗。避免单独使用白蛋白治疗未进行穿刺的肝腹水患者或非肝硬化性窦后性门静脉高压的患者。NephroticSyndromeDiuretictherapyaloneisthetreatmentofchoice.Ifdiuretictherapyfails,thenshort-termuseof25percentalbumininconjunctionwithdiuretictherapyisappropriateforpatientswithacutesevereperipheralorpulmonaryedemawhohavefaileddiuretictherapy.肾病综合征单独应用利尿治疗。急性严重性外周水肿或肺水肿的患者利尿治疗失败时，可短期应用25%的白蛋白联合利尿治疗。KidneyandLiverTransplantationTheeffectivenessofalbuminandnonproteincolloidsduringandafterrenaltransplantationsurgeryhasnotbeenconclusivelydemonstrated.Becauseofexcessivebloodloss,volu