Karın Ağrısında Sıvı Tedavisi ve Resüsitasyon

Mehmet  Ulutürk

doi:10.37609/akya.4154

Yazarlar

Mehmet Ulutürk

https://orcid.org/0000-0002-4066-3576

DOI: https://doi.org/10.37609/akya.4154.c8281

Özet

Akut karın ağrısı, acil servis başvurularının yaklaşık %5–10’unu oluşturur ve geniş bir klinik spektrumda seyredebilir. Bu hastaların başlangıç yönetiminde sıvı resüsitasyonu; hipovoleminin düzeltilmesi, doku perfüzyonunun sürdürülmesi ve şok ile çoklu organ yetmezliğinin önlenmesi açısından temel bir basamaktır. Ancak yetersiz sıvı uygulaması organ yetmezliği ve mortalite ile ilişkiliyken, aşırı sıvı yüklenmesi ise pulmoner ödem, bağırsak duvar ödemi ve abdominal kompartman sendromu gibi ciddi komplikasyonlara yol açabilmektedir. Son yıllarda, geleneksel agresif ve protokole dayalı sıvı yaklaşımlarının yerini bireyselleştirilmiş ve hedefe yönelik stratejiler almıştır. Güncel yaklaşım; erken ve yapılandırılmış klinik değerlendirme, şok indeksi ve perfüzyon belirteçleri, serum laktat düzeyi ve yatak başı ultrasonografi gibi araçlarla hastanın hemodinamik durumunun dinamik olarak izlenmesine dayanmaktadır. Resüsitasyonun sabit hacim hedefleri yerine fizyolojik sonlanım noktalarına göre titrasyonu önerilmektedir. Dengeli kristalloidler çoğu olguda ilk tercih olarak önerilmekte; sıvı tedavisi, hastanın altta yatan patolojisi, şok tipi ve klinik yanıtı doğrultusunda düzenlenmelidir. Nihai amaç, doğru hastaya doğru sıvının uygun miktar ve zamanda uygulanmasıyla yeterli doku perfüzyonunun sağlanması ve aşırı ya da yetersiz resüsitasyona bağlı komplikasyonların önlenmesidir.

Acute abdominal pain accounts for approximately 5–10% of emergency department visits and encompasses a broad clinical spectrum. In the initial management of these patients, fluid resuscitation represents a fundamental component aimed at correcting hypovolemia, maintaining tissue perfusion, and preventing shock and multiple organ failure. However, inadequate fluid administration is associated with organ dysfunction and increased mortality, whereas excessive fluid loading may lead to serious complications such as pulmonary edema, bowel wall edema, and abdominal compartment syndrome. In recent years, traditional aggressive and protocol-driven fluid strategies have been replaced by individualized and goal-directed approaches. Contemporary management relies on structured early clinical assessment and dynamic hemodynamic monitoring using tools such as shock index, perfusion markers, serum lactate levels, and point-of-care ultrasonography. Fluid therapy should be titrated according to physiological endpoints rather than fixed volume targets. Balanced crystalloid solutions are recommended as the first-line option in most cases, and fluid management should be tailored according to the underlying pathology, type of shock, and clinical response. The ultimate objective is to ensure adequate tissue perfusion by administering the right fluid, in the right amount, at the right time, while avoiding complications related to both under- and over-resuscitation.

Referanslar

Abdullah M, Firmansyah MA. Diagnostic approach and management of acute abdominal pain. Acta medi- ca Indonesiana. 2012 Oct;44(4):344-350.

Stewart BT, Maier RV. Shock, resuscitation, and fluid therapy strategies in acute care surgery: from pathop- hysiology to practice. In: Picetti E, Pereira B, Razek T, et al.(eds)Intensive care for emergency surgeons. Hot to- pics in acute care surgery and trauma. Cham: Springer; 2019. p. 155–176. doi:10.1007/978-3-030-11830-3_9.

Benes J, Kirov M, Kuzkov V, et al. Fluid therapy: double-edged sword during critical care? Bio- med Research International.2015;2015:729075. doi:10.1155/2015/729075.

de-Madaria E, Buxbaum JL, Maisonneuve P, et al. Aggressive or moderate fluid resuscitation in acu- te pancreatitis. New England Journal of Medicine. 2022;387(11):989–1000. doi:10.1056/NEJMoa2202884

He K, Gao L, Yang Z, et al. Aggressive versus controlled fluid resuscitation in acute pancreatitis: a systematic re- view and meta-analysis of randomized controlled tri- als. Chinese Medical Journal (Engl). 2023;136(10):1166– 1173. doi:10.1097/CM9.0000000000002684.

Messina A, Collino F, Cecconi M. Fluid administration for acute circulatory dysfunction using basic monito- ring. Annals of Translational Medicine 2020;8(12):788. doi:10.21037/atm.2020.04.14.

Maurer C, Wagner JY, Schmid RM, et al. Assessment of volume status and fluid responsiveness in the emer- gency department: a systematic approach. Medizi- nische Klinik – Intensivmedizin und Notfallmedizin. 2017;112(4):326–333. doi:10.1007/s00063-015-0124-x.

Mayumi T, Yoshida M, Tazuma S, et al. The practice guidelines for primary care of acute abdomen 2015. Japanese Journal of Radiology. 2016;34(1):80-115. doi:10.1007/s11604-015-0489-z.

Çardak Hakbilen M, Halhallı HC, Köksal Şimşek T, et al. Effectiveness of clinical scoring systems in durati- on of hospital stay, transfusion need and prediction of re-bleeding in patients admitted to the emergency department for upper gastrointestinal system bleeding. Sakarya Medical Journal. 2022;12(2):255-262.

Dirks NPM, Mestrom M, van der Lugt M, et al. Uti- lity of shock index for suspected rupture of abdomi- nal aortic aneurysms. Prehospital Emergency Care. 2021;25(4):496-503. doi:10.1080/10903127.2020.1796 184.

Mutschler M, Nienaber U, Münzberg M, et al. The sho- ck index revisited – a fast guide to transfusion requ- irement? A retrospective analysis on 21,853 patients derived from the TraumaRegister DGU. Critical Care. 2013;17(4):R172. doi:10.1186/cc12851.

Wong K, Kim DH, Narasimhan M. Assessment of tra- umatic acute abdomen. In: Robba C, Messina A, Wong A et al. (eds)Basic ultrasound skills “head to toe” for ge- neral intensivists: lessons from the ICU. Cham: Springer; 2023. p. 199-210. doi:10.1007/978-3-031-32462-8_14.

Kinni H, Garcia S, Clark C. Point of care ultra- sound for triage of critically ill patients in the emer- gency department.Journal of Translational Critical Care Medicine. 2024;6(3):e24-00013. doi:10.1097/ JTCCM-D-24-00013.

Elbaih AH, Housseini AM, Khalifa MEM. Accuracy and outcome of rapid ultrasound in shock and hy- potension (RUSH) in Egyptian polytrauma patients. Chinese Journal of Traumatology. 2018;21(3):156-162. doi:10.1016/j.cjtee.2017.06.009.

Davis B, Brockshus A, Merritt C, et al. Ruptured ab- dominal aortic aneurysm presenting as septic sho- ck. Military Medicine. 2020;185(11-12):e2189-e2191. doi:10.1093/milmed/usaa205.

Noble VE, Nelson BP, Sutingco AN. Echocardiography. In: Noble VE, Nelson BP, (eds)Manual of Emergency and Critical Care Ultrasound. 2nd edition. Cambridge: Cambridge University Press; 2007. p. 53–84.

Zhou Z, Li Y, Zhu J, et al. Role of the inferior vena cava collapsibility index in predicting propofol-induced hy- potension in patients undergoing colonoscopy. BMC Anesthesiology. 2025;25:73. doi:10.1186/s12871-025- 02945-y.

Alanazi MM, Alshammiri MFS, Alotaibi TO, et al. Hy- povolemic shock in critically ill patient’s early identifi- cation and impact of fluid resuscitation strategies and outcomes. International Journal of Medicine in Deve- loping Countries. 2025;9(8):1891-1896. doi:10.24911/ IJMDC.51-1754942371.

Marty P, Roquilly A, Vallée F, et al. Lactate clearance for death prediction in severe sepsis or septic shock patients during the first 24 hours in Intensive Care Unit: an observational study. Annals of Intensive Care. 2013;3(1):3. doi:10.1186/2110-5820-3-3.

Coşar MA, Gür EN. Prognostic value of lactate, lactate clearance, CRP, procalcitonin, and clinical scoring sys- tems in sepsis patients: A retrospective observational study. Journal of Surgical Arts. 2025;18(2):32-41.

Yaowmaneerat T, Sirinawasatien A. Update on the stra- tegy for intravenous fluid treatment in acute pancreati- tis. World Journal of Gastrointestinal Pharmacology and Therapeutics. 2023;14(3):22–32. doi:10.4292/wjgpt. v14.i3.22.

Pannu AK. Circulatory shock in adults in emergency department. Turkish Journal of Emergency Medicine. 2023;23(3):139-148. doi:10.4103/2452-2473.367400

Dawson A, Karunakaran M, Sharma ZD, et al. Flu- id resuscitation in the early management of acu- te pancreatitis: evidence from a systematic review and meta-analysis. HPB: The Official Journal of the International Hepato-Pancreato-Biliary As- sociation. 2023;25(12):1451–1465. doi:10.1016/j. hpb.2023.08.013.

Yuan C, Yin C. Research progress of hypertonic sali- ne in early resuscitation of acute pancreatitis. Zhong- hua Wei Zhong Bing Ji Jiu Yi Xue. 2023;35(4):446–448. doi:10.3760/cma.j.cn121430-20220811-00739.

Katz JA, Choukalas CG. Goal-directed fluid resusci- tation: a review of hemodynamic, metabolic, and mo- nitoring based goals. Current Anesthesiology Reports. 2013;3:98–104. doi:10.1007/s40140-013-0011-z.

Polderman KH, Varon J. Do not drown the patient: ap- propriate fluid management in critical illness. The Ame- rican Journal of Emergency Medicine. 2015;33(3):448- 450. doi:10.1016/j.ajem.2015.01.051.

Cannesson M, Le Manach Y, Hofer CK, et al. Asses- sing the diagnostic accuracy of pulse pressure variati- ons for the prediction of fluid responsiveness: a “gray zone” approach. Anesthesiology. 2011;115(2):231-241. doi:10.1097/ALN.0b013e318225b80a.

Engelbart J, Garcia L. Management of shock: a practi- cal guide. In: Docimo S Jr, Pauli EM, (eds)Clinical al- gorithms in general surgery. Cham: Springer; 2019. p. 727–729. doi:10.1007/978-3-319-98497-1_175.

Mutschler M, Nienaber U, Brockamp T, et al. A critical reappraisal of the ATLS classification of hypovolaemic shock: does it really reflect clinical reality? Resuscita- tion. 2013;84(3):309–313. doi:10.1016/j.resuscitati- on.2012.07.012.

Cannon JW. Hemorrhagic shock. New England Journal of Medicine. 2018;378(4):370-379. doi:10.1056/NEJM- ra1705649

Rahmadian R, Margaretha R, Ariliusra Z, et al. Fluid resuscitation and trauma management: permissive hy- potension, restricted volume, and beyond. Journal of Endovascular Resuscitation and Trauma Management. 2024;8(3):65-73. doi:10.26676/jevtm.26617.

Cap AP, Pidcoke HF, Spinella P, et al. Damage control resuscitation. Military Medicine. 2018;183(Suppl 2):36-

43. doi:10.1093/milmed/usy112

Myburgh JA. Fluid resuscitation in acute illness — time to reappraise the basics. New England Journal of Medicine. 2011;364(26):2543-2544. doi:10.1056/NEJ- Me1105490.

Popowicz P, Newman RK, Dominique E. Abdominal compartment syndrome. [Updated 2025 Sep 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan–. Available from: https://www. ncbi.nlm.nih.gov/books/NBK430932/

Rami Reddy SR, Cappell MS. A systematic review of the clinical presentation, diagnosis, and treatment of small bowel obstruction. Current Gastroenterology Re- ports. 2017;19(6):28. doi:10.1007/s11894-017-0566-9.

Nakamura Y, Kondo S, Narita K, et al. Understanding CT imaging findings based on the underlying pat- hophysiology in patients with small bowel ischemia. Japanese Journal of Radiology. 2023;41(4):353-366. doi:10.1007/s11604-022-01367-x.

Sommer NP, Schneider R, Wehner S, et al. State-of-the- art colorectal disease: postoperative ileus. International Journal of Colorectal Disease. 2021;36(9):2017-2025. doi:10.1007/s00384-021-03939-1.

Rollins KE, Lobo DN. Perioperative intravenous fluid therapy in ERAS pathways. In: Ljungqvist O, Fran- cis NK, Urman RD (eds), Enhanced Recovery After Surgery: A Complete Guide to Optimizing Outcomes. Cham: Springer; 2020. p. 167-175

Thiele RH, Raghunathan K, Brudney CS, et al. Ame- rican Society for Enhanced Recovery (ASER) and Pe- rioperative Quality Initiative (POQI) joint consensus statement on perioperative fluid management within an enhanced recovery pathway for colorectal surgery. Perioperative Medicine. 2016;5:24. doi:10.1186/s13741- 016-0049-9.

Resalt-Pereira M, Muñoz JL, Miranda E, et al. Go- al-directed fluid therapy on laparoscopic colorectal surgery within enhanced recovery after surgery prog- ram. Revista Española de Anestesiología y Reanimación. 2019;66(5):259-266. doi:10.1016/j.redar.2019.01.007.

Myles PS, Bellomo R, Corcoran T, et al. Restrictive versus liberal fluid therapy for major abdominal sur- gery (RELIEF trial). New England Journal of Medicine. 2018;378:2263-2274. doi:10.1056/NEJMoa1801601.

Zorrilla-Vaca A, Mena GE, Ripolles-Melchor J, et al. Goal-Directed Fluid Therapy and Postoperative Out- comes in an Enhanced Recovery Program for Colore- ctal Surgery: A Propensity Score-Matched Multicenter Study. The American Surgeon. 2021;87(8):1189-1195. doi:10.1177/0003134820973365.

Miller TE, Roche AM, Mythen M. Fluid management and goal-directed therapy as an adjunct to Enhanced Recovery After Surgery (ERAS). Canadian Journal of Anaesthesia. 2015;62(2):158-168. doi:10.1007/s12630- 014-0266-y.

García-Sánchez FJ, Roque-Rojas F, Mudarra-García N. From Emergency Department to Operating Room: The Role of Early Prehabilitation and Perioperative Care in Emergency Laparotomy: A Scoping Review and Practical Proposal. Journal of Clinical Medicine. 2025;14(19):6922. doi:10.3390/jcm14196922.