Инфузионная терапия пациентов в критическом состоянии (состояние проблемы). Часть 1

Инфузионная терапия является важным компонентом лечения многих заболеваний и одним из основных методов интенсивной терапии пациентов реанимационного профиля. Активная инфузионная терапия с использованием разных инфузионных сред, больших объемов и высоких скоростей внутривенного введения жидкости особенно актуальна у пациентов, пострадавших и раненых, в критическом состоянии, наиболее тяжелым из которых остается септический шок. На протяжении более двух столетий клинического применения инфузионная терапия прошла большой эволюционный путь и стала более эффективной и безопасной. Однако, как и любое лекарственное средство, инфузионная терапия (в целом и конкретные инфузионные среды) имеет ряд побочных эффектов, особенно при ее чрезмерном использовании. Поэтому в последние годы применение инфузионной терапии рассматривается как назначение любого лекарства с учетом показаний, противопоказаний, способов введения, дозирования, продолжительности, деэскалации. Это позволило выделить основные этапы инфузионной терапии критических состояний и шока: интенсивная инфузионная терапия (быстрое введение большого объема жидкости), оптимизация инфузионной терапии (снижение скорости и объема инфузии), стабилизация пациента и минимизация инфузии, дереанимация (удаление избыточной жидкости из организма). По мере развития клинической патофизиологии были пересмотрены основные представления о поддержании жидкостного гомеостаза организма в норме и при критических состояниях, изучены отрицательные эффекты инфузионной терапии на всех этапах ее применения. Поэтому при интенсивной терапии шока основными клиническими вопросами являются: когда следует начинать инфузионную терапию, когда прекращать активную инфузионную терапию, когда начинать удаление жидкости из организма и когда прекращать жидкостную дереанимацию. Таким образом, для реализации принципа персонифицированного лечения важно определить не только «переносимость» инфузионной терапии, но и «чувствительность» к инфузии конкретного пациента – возможность поддержания гемодинамики без риска перегрузки жидкостью. Оценка рутинных клинических, инструментальных и лабораторных показателей состояния макро- и микроциркуляции не дает возможность прецизионно ответить на эти вопросы. Современные сонографические методы мониторинга центральной и периферической кардиогемодинамики, «венозного избытка» с использованием доплеровской и расширенной фокусной эхокардиографии позволяют оценить «переносимость инфузионной терапии». Реализация этого нового направления повысит эффективность и безопасность инфузионной терапии и улучшит результаты лечения пациентов в критическом состоянии. 

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