#16
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À âîò âñòðåòèëñÿ òàêîé ãàéä ïî æèäêîñòíîé ðåàíèìàöèè, ñ èíòåðåñíûìè ðåêîìåíäàöèÿìè. Âîò òàê âçÿëè è ðàññòàâèëè òî÷êè íàä ¨: [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ]
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#17
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Âîò è ìíå òàê ïîêàçàëîñü... Ãàéäû - äåëî õîðîøåå, íî èõ â âåíó íå âîëüåøü. Åñëè àäìèíèñòðàöèÿ óïîðíî íå æåëàåò îáåñïå÷èâàòü áîëüíèöó íåîáõîäèìûìè ïðåïàðàòàìè (íåîòëîæíîé ïîìîùè!), òî åäèíñòâåííûé âûõîä - áåæàòü îòòóäà êàê ìîæíî ñêîðåå. Èáî ñïàñàòü ëþäåé ìîæíî è â äðóãîé áîëüíèöå, à ðèñêîâàòü ñâîåé ñîâåñòüþ è ðåïóòàöèåé èç-çà ïîôèãèçìà ÷èíîâíèêîâ - ýòî äàæå íå àëüòðóèçì, à âîîáùå ÷òî-òî çàïðåäåëüíîå.
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#18
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Ó Âàñ òðóäíîñòè ñ ôèçðàñòâîðîì? Èëè íåäîâîëüñòâî âîîáùå? Áûëî âûäåëåíî íå÷òî ïîëåçíîå èç "ãîâîðèëüíîé òåìû". Âîçìîæíî, êîìó òî íóæíîå. Êòî òî áóäåò ÷èòàòü. Çà÷åì îïÿòü ãîâîðèëüíÿ?
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#19
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Ïðîøó ïðîùåíèÿ çà ãîâîðèëüíþ, íî, ê ñîæàëåíèþ, ñëåäóåò îòäàòü äîëæíîå ýôôåêòèâíîñòè ìàðêåòîëîãîâ ïðîèçâîäèòåëåé êðàõìàëîâ.
Èõ áóðíàÿ äåÿòåëüíîñòü íà ôîíå ÿçû÷åñêîé âåðû â [S]æèâóþ âîäó[/S] "äåòîêñèêàöèîííûå/ðåîëîãè÷åñêèå" ñâîéñòâà êîëëîèäîâ ïðèâåëà ê ïðàêòè÷åñêè ïîëíîé çàìåíå äåêñòðàíîâ (êñòàòè, â ÐÔ òàê è íå áûë çàðåãèñòðèðîâàí îäíîòûñÿ÷íûé äåêñòðàí) íà êðàõìàëû, ÷òî áûëî âïîëíå îáîñíîâàíî. Ïðåêðàñíî ïîíèìàþ, ÷òî íèêàêîé ìàðêåòîëîã ïî îïðåäåëåíèþ íå áóäåò ñîêðàùàòü ïîòåíöèàë ðûíêà (ï÷åëû ïðîòèâ ìåäà), è â ðåçóëüòàòå - ïðàêòè÷åñêè íèêàêèõ óïîìèíàíèé ïî-ðóññêè, ÷òî êðàõìàëû èñêëþ÷èòåëüíî âòîðàÿ ëèíèÿ òåðàïèè, êàê èòîã - óíèêàëüíàÿ óðîäëèâàÿ ñèòóàöèÿ - ðåäêàÿ èíôóçèÿ îáõîäèòñÿ áåç êðàõìàëà. Íå ìîãó íå ïîâòîðèòüñÿ, ãîâîðÿ î ãåìîððàãè÷åñêîì øîêå - ñëåäóåò ïðèëîæèòü âñå óñèëèÿ äëÿ äîñòóïíîñòè è ðàöèîíàëüíîãî ïðèìåíåíèÿ èìåííî êîìïîíåíòîâ êðîâè, à íå ñåòîâàòü íà îãðàíè÷åíèÿ ïîñòàâîê êðàõìàëîâ (îá ýòîì ìàðêåòîëîãè ñïîñîáíû è ñàìîñòîÿòåëüíî ïîçàáîòèòüñÿ). |
#20
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ìíå êàæåòñÿ, ýòî íå òîëüêî âñëåäñòâèå äåÿòåëüíîñòè ìàðêåòîëîãîâ: äåêñòðàíû ñ÷èòàþòñÿ ìåíåå óäîáîâàðèìûìè êîëëîèäàìè, ñðåäè êðàõìàëîâ ìèçêîìîëåêóëÿðíûå âûãëÿäÿò íàèáîëåå ïðèåìëåìûìè...
Dextrans appear to have the most unfavourable risk/benefit ratio among the currently available synthetic colloids due to their relevant anaphylactoid potential, risk of renal failure and, particularly, their major impact on haemostasis. The effects of gelatin on kidney function are currently unclear, but potential disadvantages of gelatin include a high anaphylactoid potential and a limited volume effect compared with dextrans and HESs. Modern HES preparations have the lowest risk of anaphylactic reactions among the synthetic colloids. Older HES preparations (hetastarch, hexastarch and pentastarch) have repeatedly been reported to impair renal function and hemostasis, especially when the dose limit provided by the manufacturer is exceeded, but no such effects have been reported to date for modern tetrastarches compared with gelatin and albumin. However, no large-scale clinical studies have investigated the impact of tetrastarches on the incidence of renal failure in critically ill patients. When considering the efficacy and risk/benefit profile of synthetic colloids, modern tetrastarches appear to be most suitable for intensive care medicine, given their high volume effect, low anaphylactic potential and predictable pharmacokinetics. Best Pract Res Clin Anaesthesiol. 2009 Jun;23(2):193-212. Relevance of non-albumin colloids in intensive care medicine.
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Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
#21
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Ýòî áèòâà ãèãàíòîâ áóäåò âå÷íîé. Ñåé÷àñ ìàëî êòî îñïàðèâàåò ïðåèìóùåñòâî êðàõìàëîâ íàä äåêñòðàíàìè â êîëè÷åñòâå ïîáî÷íûõ ÿâëåíèé. Ïî ýôôåêòèâíîñòè æå è â ñòàòüå, ïðèâåäåííîé Âàäèìîì Âàëåðüåâè÷åì, â ñðàâíåíèè êðàõìàëà è äåêñòðàíà àâòîðû ññûëàþòñÿ íà ýòî èññëåäîâàíèå: [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ]
Öèòàòà:
Öèòàòà:
À â ñðàâíåíèè êðàõìàëîâ ìåæäó ñîáîé, ó àâòîðîâ ñòàòüè âñå îñíîâàíî íà èññëåäîâàíèÿõ ñ ñóððîãàòíûìè êîíå÷íûìè òî÷êàìè, îöåíèâàÿ îáúåì ïåðèîïåðàöèîííîé êðîâîïîòåðè è ñîîòâåòñòâåííî äåëàÿ âûâîäû î âëèÿíèè íà ãåìîñòàç. Âñå æå âèäèìî èìååò ñìûñë ðóêîâîäñòâîâàòüñÿ îáçîðîì [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] Öèòàòà:
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#22
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Öåëèêîì ñîãëàñåí ñ Êîêýéíîâñêèì îáçîðîì, ÍÎ! íà ñåãîäíÿøíèé äåíü íå âåäåòñÿ íè îäíîãî òðàéëà, ñðàâíèâàþùåãî êîëëîèäû ìåæ ñîáîé, òîëüêî ñ êðèñòàëëîèäàìè:
Completed Saline Solution Versus Voluven®: A Controlled Study of Fluid Resuscitation in Severe Sepsis Condition: Sepsis Interventions: Drug: Resuscitation (Voluven); Drug: Resuscitation (Saline) Completed Colloids in Severe Trauma Conditions: Abdominal Hypertension; Abdominal Compartment Syndrome; Severe Trauma Intervention: Drug: tetrastarch (Voluven) Not yet recruiting Crystalloid Versus Hydroxyethyl Starch Trials Condition: Intensive Care Interventions: Drug: 6% Hydroxy-ethyl starch (130/0.4); Drug: Saline Recruiting Crystalloids vs. Colloids During Surgery Conditions: Fluid Therapy; Morbidity Interventions: Drug: Lactated Ringer's Solution; Drug: Hydroxyethylstarch 6% 130/0.4
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Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
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#23
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Õîòÿ ÿ ðàíåå íåîäíîêðàòíî ëîìàë êîïüÿ â ñïîðå ñ îïïîíåíòàìè (íà ïàðàëëåëüíûõ ôîðóìàõ), âûñòóïàÿ çà ìàêñèìàëüíî ðåñòðèêòèâíîå èñïîëüçîâàíèå àëüáóìèíà è èñêóññòâåííûõ êîëëîèäîâ ó êðèòè÷åñêèõ áîëüíûõ, íåäàâíî ïîïàëèñü ìíå ïàðó èíòåðåñíûõ ñòàòåé, â êîòîðûõ ïîêàçàí ïîçèòèâíûé ýôôåêò îíûõ ñóáñòàíöèé, ïî ñðàâíåíèþ ñ êðèñòàëëîèäàìè ó íåêîòîðûõ ïîïóëÿöèé áîëüíûõ. Õî÷ó èõ çäåñü ïðîöèòèðîâàòü:
Albumin Administration Improves Organ Function In Critically Ill Hypoalbuminemic Patients: A Prospective, Randomized, Controlled, Pilot study Marc-Jacques Dubois, Carlos Orellana-Jimenez, Christian Melot, et al. Crit Care Med. 2006;34(10):2536-2540 Abstract Objective: To test the hypothesis that administration of albumin to correct hypoalbuminemia might have beneficial effects on organ function in a mixed population of critically ill patients. Design: Prospective, controlled, randomized study. Setting: Thirty-one-bed, mixed medicosurgical department of intensive care. Patients: All adult patients with a serum albumin concentration =30 g/L were assessed for eligibility. Principal exclusion criteria were expected length of stay <72 hrs, life expectancy <3 months or a do-not-resuscitate order, albumin administration in the preceding 24 hrs, or evidence of fluid overload. Interventions: The 100 patients were randomized to receive 300 mL of 20% albumin solution on the first day, then 200 mL/day provided their serum albumin concentration was <31 g/dL (albumin group), or to receive no albumin (control group). Measurements and Main Results: The primary outcome was the effect of albumin administration on organ function as assessed by a delta Sequential Organ Failure Assessment score from day 1 to day 7 (or the day of intensive care discharge or death, whichever came first). The two groups of 50 patients were comparable at baseline for age, gender, albumin concentration, and Acute Physiology and Chronic Health Evaluation II score. Albumin concentration did not change over time in the control group but increased consistently in the albumin group (p < .001). Organ function improved more in the albumin than in the control group (p = .026), mainly due to a difference in respiratory, cardiovascular, and central nervous system components of the Sequential Organ Failure Assessment score. Diuretic use was identical in both groups, but mean fluid gain was almost three times higher in the control group (1679 ± 1156 vs. 658 ± 1101 mL, p = .04). Median daily calorie intake was higher in the albumin than in the control group (1122 [935-1158] vs. 760 [571-1077] kcal, p = .05). Conclusions: Albumin administration may improve organ function in hypoalbuminemic critically ill patients. It results in a less positive fluid balance and a better tolerance to enteral feeding. http://www.medscape.com/viewarticle/551283 ************* Effects of hydroxyethyl starch resuscitation on extravascular lung water and pulmonary permeability in sepsis-related acute respiratory distress syndrome Huang, Chung-Chi; Kao, Kuo-Chin; Hsu, Kuang-Hung; Ko, How-Wen; et al. Critical Care Medicine: June 2009 - Volume 37 - Issue 6 - pp 1948-1955 Abstract Objective: Hydroxyethyl starch (HES) has greater volume expansion effect and longer intravascular persistence than crystalloids. HES also decreases microvascular permeability and capillary leakage by biophysically plugging endothelial leaks, exerting an anti-inflammatory effect, and decreasing activation of endothelial cells. The aim of our study was to determine whether medium molecular weight HES (pentastarch) resuscitation in the early stage of acute respiratory distress syndrome (ARDS) simultaneously increases cardiac output without worsening pulmonary edema and whether it attenuates pulmonary vascular permeability. Design: Prospective observational study. Setting: Twenty-bed medical intensive care unit of a tertiary medical center. Patients: Twenty patients with early-stage ARDS. Intervention: Volume expansion with a 500-mL infusion of 10% pentastarch (HES 200/0.5) at a rate of 10 mL/kg/hr. Measurements and Main Results: Baseline hemodynamics including systemic and pulmonary artery blood pressures, central venous pressure, pulmonary artery occlusion pressure, and cardiac output were obtained from an online HP Component Monitoring System and a pulmonary artery catheter. Intrathoracic blood volume (ITBV), global end-diastolic volume, extravascular lung water (EVLW), and pulmonary vascular permeability (EVLW/ITBV) were measured with a PiCCOplus monitor. Hemodynamic measurements were repeated immediately and 2, 4, and 6 hours after volume expansion. Pentastarch loading significantly increased central venous pressure, pulmonary artery occlusion pressure, pulmonary arterial pressures, and cardiac output. Pulmonary mechanics, venous admixtures, and EVLW values remained unchanged throughout the study. EVLW/ITBV significantly decreased immediately after the pentastarch infusion. Conclusions: In patients with early ARDS, pentastarch resuscitation significantly improved their hemodynamics and cardiac output without worsening pulmonary edema and pulmonary mechanics. It even attenuated pulmonary vascular permeability. www.ncbi.nlm.nih.gov/pubmed/19384203 |
#24
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Êîëëåãè, íà ýòîì ôîðóìå çàïðåùåíî ïóáëè÷íîå îáñóæäåíèå äåéñòâèé ìîäåðàòîðà è ëè÷íàÿ ïåðåïèñêà â ìåäèöèíñêèõ òåìàõ. Çà íàðóøåíèÿ âûäàþòñÿ øòðàôíûå áàëëû. Ñîîáùåíèÿ, íå èìåþùèå îòíîøåíèÿ ê îáñóæäàåìîìó òîïèêó ÿ ñêðîþ.
all we need is love äàâàéòå æèòü äðóæíî |
#25
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Äà ðàäè Áîãà! Òîëüêî íà÷èíàéòå, ïîæàëóéñòà, ïîðàíüøå. ß âîîáùå íèêîãî íå òðîãàþ, îòâå÷àþ òîëüêî ïî ñóùåñòâó è òîëüêî àâòîðàì òåìû. ×òî ìíå òåïåðü, ìîë÷à òåðïåòü âñå ýòè íàñêîêè? Òî ôëåáîëîã ìèìîõîäÿùèé âëåïèë øòðàôíûå áàëëû "çà ôëóä" (êðóïíûé ñïåöèàëèñò â èíôóçèîííîé òåðàïèè!), òî Âëàä áåç êîíöà çàäèðàåòñÿ, õîòÿ ó ñàìîãî åäâà ÷åòâåðòü ñîîáùåíèé íåñóò êàêóþ-òî ïîëåçíóþ èíôîðìàöèþ, äà è òî ñïëîøíûå ãàéäû... Ñîáññíî, åñëè ýòî èìåííî ÿ íàðóøàþ õðóïêîå ðàâíîâåñèå ôîðóìà, òî ìîãó è óäàëèòüñÿ îòñþäà ïî ïåðâîìó òðåáîâàíèþ. Âàøå ñëîâî - çàêîí, à Èíòåðíåò áîëüøîé...
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#26
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Óâàæàåìûé Àëåêñàíäð Ñåðãååâè÷,
Ñïàñèáî çà ññûëêè, ïî ïåðâîé ñòàòüå ìîãó òåîðåòè÷åñêè ïðåäïîëîæèòü, ÷òî ïîääåðæàíèå ìèíèìàëüíîãî îíêîòè÷åñêîãî äàâëåíèÿ è/èëè àëüáóìèíåìèè âñå æå èìååò ñâîè ïðåèìóùåñòâà (òàê æå êàê ïîääåðæàíèå ýëåêòðîëèòíîãî/èîííîãî ñîñòàâà, ðÍ êðîâè, ãåìîãëîáèíåìèè). Ãîðàçäî áîëåå èíòåðåñíûì áûëî áû óâèäåòü âêëþ÷åíèå â ýòî èññëåäîâàíèå è ãðóóïïû ïàöèåíòîâ ñ íîðìàëüíûì àëüáóìèíîì è ðàíäîìèçàöèåé... Ïî âòîðîìó: ìÿãêèå òî÷êè òîæå èíòåðåñíû, íî âñå æåëàþò çíàòü, à ÷òî æå â èñõîäå? òàê ÷òî ïîäîæäåì ðåçóëüòàòîâ óæå çàâåðøåííîãî: Colloids in Severe Trauma (CIST) - This study will serve as a pilot to test the hypothesis that there will be significant differences in clinical outcomes for patients with severe trauma treated with colloid (HES) plus crystalloid and crystalloid only fluid management regimens, most notably the incidence of IAH and ACS. Ïîõîæå, ïîëó÷èòñÿ ñüåçäèòü íà åæåãîäíóþ øîêîâóþ êîíôó â Øòàòàõ, ÷òî áóäåò â Ïîðòëàíäå â èþíå, áûòü ìîæåò òàì äîëîæàò î ðåçóëüòàòàõ...
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Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
#27
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Îòêðîâåííî, ñòàòüÿ Albumin Improves Organ Function In Critically Ill Hypoalbuminemic Patients ÷åì òî íàïîìíèëà [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ]
Ãèïîàëüáóìèíåìèÿ íå åñòü õîðîøî, è èíôóçèÿ àëüáóìèíà, ïîâûøàÿ åãî óðîâåíü óëó÷øàåò ñîñòîÿíèå. ×åãî õîòåëè äîêàçàòü íå ÿñíî. À âîò Effects of hydroxyethyl starch resuscitation on extravascular lung water and pulmonary permeability in sepsis-related acute respiratory distress syndrome - îñòàâèëà ñòðàííîå âïå÷àòëåíèå. Âðîäå âñå ïðàâèëüíî, è ýôôåêò îæèäàåìûé ñ òî÷êè çðåíèÿ ïàòîôèçèîëîãèè, íî òîëüêî ðàñõîäèòñÿ ýòî ñ ìíåíèåì âûñêàçàííûì ÷óòü ðàíåå, íà òîé æå ãðóïïå áîëüíûõ (ñåïñèñ), ãäå è áîëüíûõ áûëî ïîáîëüøå è íàáëþäàëèñü îíè ïîäîëüøå: [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] Âòîðàÿ ÷àñòü èññëåäîâàíèÿ êàê ðàç è ïîñâÿùàëàñü ñðàâíåíèþ ïåíòàñòàð÷à ñ Ðèíãåð-ëàêòàòîì. Öèòàòà:
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#28
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Öèòàòà:
Äâà êðóïíûõ ìåòààíàëèçà ïî àëüáóìèíó, â 90-õ ïîêàçàëè ïîâûøåíèå ñìåðòíîñòè ïðè èñïîëüçîâàíèè îíîãî ïî ñðàâíåíèþ ñ êðèñòàëëîèäàìè â îáùåé ïîïóëÿöèè êðèòè÷åñêèõ áîëüíûõ.  îäíîì, íàñêîëüêî ÿ ïîìíþ, óêàçûâàëîñü, ÷òî òîëüêî ôàêò èíôóçèè àëüáóìèíà ìîæåò âûçûâàòü 5 äîïîëíèòåëüíûõ ñìåðòåé íà 100 ïàöèåíòîâ, ó êîòîðûõ îíà èñïîëüçîâàëàñü. Ýòî ïîðîäèëî ðàäèêàëüíóþ êîíöåïöèþ "No more albumin !".  äàëüíåéøåì êðóïíîå èññëåäîâàíèå SAFE ïîêàçàëî ðàâíóþ ýôôåêòèâíîñòü èíôóçèè àëüáóìèíà (â îòíîøåíèè êîíå÷íûõ òî÷åê), ïî ñðàâíåíèþ ñ êðèñòàëëîèäàìè ("à åñëè íåò ðàçíèöû, çà÷åì ïëàòèòü áîëüøå ?" (ñ)). Åäèíñòâåííàÿ ñóáïîïóëÿöèÿ ó êîòîðîé àëüáóìèí â ýòîì èññëåäîâàíèè ïðèâîäèë ê ñòàòèñòè÷åñêè çíà÷èìîìó ïîâûøåíèþ ëåòàëüíîñòè - áîëüíûå ñ òÿæåëîé ×ÌÒ. Ïðîáëåìà â òîì, ÷òî îñíîâíàÿ ïðè÷èíà ãèïîàëüáóìèíåìèè ó ïàöèåíòîâ ñ êðèòè÷åñêèìè ñîñòîÿíèÿìè - êàïèëëÿðíàÿ óòå÷êà (capillary leak) è äîïîëíèòåëüíî ââåäåííûé àëüáóìèí òàêæå óéäåò â èíòåðñòèöèé, óâëåêàÿ çà ñîáîé âîäó, ÷òî ïðèâåäåò, â ÷àñòíîñòè ê óõóäøåíèþ ðåñïèðàòîðíîé ôóíêöèè.  êà÷åñòâå èëëþñòðàöèè - êàðòèíêè, êîòîðûå Ëåîíèä íåêîòîðîå âðåìÿ íàçàä ïîñòèë íà ðóñàíåñòå. Ýëåêòðîííàÿ ìèêðîôîòîãðàôèÿ íîðìàëüíîãî ñîåäèíåíèÿ ýíäîòåëèàëüíûõ êëåòîê: [Èçîáðàæåíèÿ äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì] ×åðåç ÷àñ ïîñëå ââåäåíèÿ ñóáñòàíöèè P: [Èçîáðàæåíèÿ äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì] McDonald DM, Thurston G, Baluk P.Endothelial gaps as sites for plasma leakage in inflammation. Microcirculation 1999; 6:7-22 Àëüáóìèí è äàæå áîëåå êðóïíûå ìîëåêêóëû óëåòàþò ñî "ñâèñòîì". Òàê ÷òî âîïðîñ î÷åíü íåîäíîçíà÷íûûé è èññëåäîâàíèå, êîòîðîå ïîêàçàëî ïîçèòèâíûé ýôôåêò àëüáóìèíà íà êîíå÷íûå òî÷êè ó êðèòè÷åñêèõ áîëüíûõ íà ýòîì îáùåì ôîíå ñìîòðèòñÿ âåñüìà óäèâèòåëüíî. |
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À ìîæåò áûòü äåëî â àêêóðàòíîì âûáîðå ïàöèåíòîâ? ×òî òàêîå "êàïèëëÿðíàÿ óòå÷êà"? Âñåãäà ëè îíà?  êàêîé ñòåïåíè? Åñòü ýëåìåíò ðàññóæäåíèÿ ÈÌÕÎ. À êàê åå ìîæíî çàïîäîçðèòü êëèíè÷åñêè? Ïðåäïîëîæó, ÷òî íàëè÷èåì âíåñîñóäèñòîé ãèïåðãèäðàòàöèè. À ÷òî ïîäðçóìåâàëîñü ïîä ñëîâàìè Fluid overload â êðèòåðèÿõ èñêëþ÷åíèÿ? Íå òóò ëè ñîáàêà ïîðûëàñü?
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