The only reason to give a patient a fluid challenge (fluid bolus) is to increase the patient's stroke volume. This concept is referred to as fluid responsiveness, which is best defined as an increase in the stroke volume index (SVI) of greater than 10% following a 500 ml fluid bolus.快速补液的唯一理由就是增加搏出量，这一概念也即液体反应性，最好的定义就是补液500ml后搏出量指数(SVI)增加超过10%。
二、血流动力学不稳定，仅一半人有液体反应Clinical studies across heterogenous populations of patients including those with sepsis, trauma, pancreatitis, burns as well as intraoperative and postoperative patients have consistently and reproducibly demonstrated that only about 50% of hemodynamically unstable patients are fluid responsive. This implies that approximately 50% of hemodynamically unstable patients will not benefit from a fluid bolus and that a fluid bolus could potentially be harmful.这就意味着，一半的血流动力学不稳定的患者不能从快速补液中获益，甚至可能是有害的。
三、有创无创都好用，动态评估有意义Both noninvasive as well as minimally invasive cardiac output monitors are useful in determining fluid responsiveness in shocked patients by assessing the response to a passive leg raising maneuver (PLR) or fluid bolus. The SVI (or cardiac output) should be monitored dynamically and in real-time as the maximal change in SVI has been reported to occur after 1.2 min with return to the baseline hemodynamic profile after 10 min.Paradoxically, this approach may reduce the risk of acute kidney injury and the duration of vasopressor support. In critically ill patients with renal, cardiac, or respiratory failure, transpulmonary thermodilution monitoring with measurement of the extravascular lung water index (EVLWI) and global end-diastolic volume index (GEDI) will provide additional data to guide fluid resuscitation
四、目标导向复苏，EVLWI和GEDI作用大Goal-directed fluid management based on fluid responsiveness has been shown to reduce mortality, as well as duration of mechanical ventilation.Paradoxically, this approach may reduce the risk of acute kidney injury and the duration of vasopressor support. In critically ill patients with renal, cardiac, or respiratory failure, transpulmonary thermodilution monitoring with measurement of the extravascular lung water index (EVLWI) and global end-diastolic volume index (GEDI) will provide additional data to guide fluid resuscitation.目标导向复苏可以降低病死率，缩短机械通气时间，降低AKI风险和血管加压药使用时间。危重病人测量EVLWI和GEDI可以提供非常有用的复苏指导信息。
五、CVP不可靠，不应用来指导液体管理Static ‘preload’ parameters, such as the central venous pressure (CVP), pulmonary capillary wedge pressure (PCWP), venal caval diameter, and so forth are unreliable and should not be used to guide fluid management.
六、晶体液效果短暂，需注意！Crystalloids ‘resuscitate’ predominantly the interstitial compartment with less than 20% remaining intravascular after about 2 h. Consequently, the hemodynamic benefit, as reflected by the SVI and MAP, is short lived, typically lasting for less than 1 h.一般血流动力学获益持续不超过1小时。
七、床旁超声有助于休克鉴别The major category of shock must be rapidly determined; this is based on a focused history and clinical examination. Within a few minutes, the presumptive category of shock should be ‘clinically obvious’ in the vast majorly of patients with shock. A bed-side-focused transthoracic echocardiographic examination is a simple, readily available intervention that can provide vital information in supporting the clinical diagnosis. Bed-side echocardiography allows for the rapid determination of left and right ventricular function, as well the detection of cardiac tamponade, major valvular disease, and hypertrophic obstructive cardiomyopathy (HOCM). Although echocardiography can usually support a diagnosis of severe volume depletion, it is less useful in assessing volume status and fluid responsiveness. In the modern ICU, echocardiography (as performed by intensivist) plays a major role in the initial and ongoing assessment of patients with hemodynamic instability.
但心超对于容量状态和液体反应性的评估作用不大。
八、液体复苏策略切忌一刀切！A one-size-fits-all fluid treatment strategy is exceedingly dangerous and will increase patient morbidity and mortality. The approach to the resuscitation of any patient with shock must be individualized and based on the type of shock, the patient's comorbidities (and hemodynamic reserve) as well as the patients’ hemodynamic and respiratory status.
九、快速补液每次500ml，必要时重复进行The ideal volume of a fluid bolus/fluid challenge is somewhat controversial. The FENICE study was a global inception cohort study, which evaluated fluid challenges in 2213 patients in 311 centers in 46 countries. In this study, the median (interquartile range) amount of fluid given during a fluid challenge was 500 ml (500–1000). studied the hemodynamic effect of different doses of fluids in postcardiac surgery patients. These investigators reported that the predicted minimal volume required for a fluid challenge was between 321 and 509 ml and that at least 4 ml/kg was required to reliably increase the mean circulating filling pressure and to distinguish fluid responders from nonresponders.On the basis of this data, and for simplicity and standardization we suggest that fluid is best administered as 500 ml boluses of crystalloid with repeat boluses as clinically indicated.The patient's physiologic response to a fluid bolus should be closely monitored and only those who have shown a beneficial effect should cautiously receive further boluses of fluid.
说了这么多，上述标红的句子是结果，为了简便和标准化，我们建议最好是每次使用500ml晶体液进行快速补液，评估后如果还要补，继续用500ml，以此类推。
十、平衡晶体液是快速补液的选择Under almost all circumstances, a balanced crystalloid (e.g. Lactated Ringers solution) is the crystalloid of choice; this includes patient with diabetic ketoacidosis, burns, trauma, sepsis, pancreatitis, and so forth.
了解更多，请点击阅读原文来源：https://oce.ovid.com/article/00075198-201906000-00010/HTML
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