98/10-EBM Homework-fluid replacement post operation

EBM(evidence base medicine)是最近一直很夯的話題,不只整個台灣,可說全世界的醫學都大力的推廣。從clerk, intern一直到Resident,每個月到不同的科別,都還是得要交出這麼一份EBM的報告。
又來了,再次鑑於小弟實在很會混水摸魚,還是乖乖的把自己的報告提出來給大家笑一笑,有笑才有進步的空間,請大家不吝於給我指導。
說實在的,要不是真的有報告的壓力,還不會努力的想去認識一下EBM這種繁文縟節的形式(於我這種沒有耐心的個性不合...),所以我該感謝醫策會規劃的PGY制度嗎?

回歸正題,用GOOGLE搜尋"EBM"第三個連結是國泰醫院的實證醫學中心,這個網站做的真是精美......,裡面也有很棒的教學,個人感覺他的"動手作EBM線上指導"超讚的,和大家分享,希望我自己也能經常運用於臨床,才不會覺得自己每天都在作常規事務而沒學到知識。

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Evidence Base Medicine
P(Patient/Problem): 68 years old woman with ovary cancer, adenocarcinoma, stage IIIc, status post maximal debulking
Oligouria after surgery, should we keep to give fluid liberal?
I(Intervention): NaCl 0.225% with Dextrose 5% 1000ml QD(125ml/hr)
C(Comparison): Add NaCl 0.225% with Dextrose 5% 500ml stat as fluid challenge
O(Outcome): Urine amount increase
Search Key word: fluid replacement of operation
Search tool: PubMed
Search result: All:1686; Free full text:244; Review: 240
挑選了Review中的第10篇
A rational approach to perioperative fluid management.
Chappell D, Jacob M, Hofmann-Kiefer K, Conzen P, Rehm M.
Anesthesiology. 2008 Oct;109(4):723-40. Review.
這是一篇review,作者一共review了198篇paper,從中整理出幾個和perioperative fluid management有關的主題來探討。
和我們設定的主題相關的是「“Liberal,” “Standard,” or “Restrictive”: It’s in the Eye of the Beholder」以及「Major Surgery」
當中提到了,目前的各項研究,彼此之間對於fluid therapy的作法往往相互衝突,無法歸納出真正適用的guildline,其中很大的原因是,大家選取的輸液標準量都有所不同,A實驗者認定的Liberal的輸液量,在B實驗者的實驗中可能是restrictive的量。另外,實驗本身沒有設計成針對病人的狀況(hypovolemia或normovolemia),反而以liberal和restrictive來設計,也很奇怪。
(原文如下):Results of studies on fluid therapy will have an impact on everyday practice only if clinicians are able to accept one or more alternative regimens as being superior. Many clinicians are reluctant to change their fluid practices, impeding research on perioperative fluid handling and acceptance of protocol-based improvements. Research suffers not only from an almost unascertainable target, but traditionally from a lack of standardization, complicating the design of control and study groups. Investigators have normally named their traditional regimen the standard group and compared it with their own restrictive ideas. Consequently, a restrictive regimen in one study is often designated as liberal in another setup. In addition, studies claiming to compare restrictive versus liberal use of fluid should, in part, rather be interpreted as investigating hypovolemia versus normovolemia.
取liberal和restrictive相比的好處在於可以省略很多變項,像是patient原本使用的點滴量、術後是否有給止痛止吐的藥、未開刀前是否有cardial pulmonary disease、住院天數長短甚至開刀的術式和時間等等。因此作者建議,目前可以先規範出大方向,比方說先比較abdominal 和nonabdominal surgery。
(原文如下):
This shortcoming prevents even promising results from impacting daily clinical routine and makes any pooling of the data impossible. A further important limitation of the data in this field is the target of a given study. Perioperative fluid handling has been related to, among other things, nausea and vomiting, pain, tissue oxygenation, cardiopulmonary disorders, need of revision surgery, duration of hospital stay, and bowel recovery time. However, the relevance of each individual target depends on the examined type and extent of surgery, which in turn has an enormous influence on changes and significance of these outcome parameters. Avoiding postoperative nausea and vomiting(PONV) in cardiopulmonary-healthy patients, for example, might be the most important goal after a 15-min knee arthroscopy. By contrast, it is merely a minor issue after a 6-h major abdominal intervention, in which cardiopulmonary complications or mortality rates are in the spotlight. Therefore, a careful differentiation between large and small operations, as well as abdominal versus nonabdominal surgery, seems to be necessary.
目前幾個比較大型的trial都偏向結果是採用restrictive的fluid supply對於病人的outcome較佳。Lobo et al. 在20個病人的實驗中,將病人randomized的分成兩組,其中一組是restrictive(﹤2L/day),另外一組是standard(>3L/day),後面這組明顯造成體重增加,腸蠕動功能恢復變慢且延長住院天數。Nisanevic et al.在他們的研究中比較了使用1.2L/day和3.7L/day,發現較少輸液的組別會減少術後死亡率且縮短住院天數。Holte 和Kehlet在80個randomized clinical trials中做出歸納:建議避免fluid overload在執行major surgical procedures。
(原文如下)
As a conclusion of a systematic review of 80 randomized clinical trials, Holte and Kehlet43 recently recommended avoiding “fluid overload in major surgical procedures.”

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