大面积烧伤休克期心功能变化监测的研究

目的观察大面积烧伤休克期心功能监测对复苏的指导意义。方法对入院后置入Swan-Ganz漂浮导管的15例大面积烧伤病人,采用血流动力学监测仪,于入院时及伤后8、16、24、36、48 h连续监测患者的心排量(CO)、心排指数(CI)、每搏量(SV)、每搏指数(SI)、右房压(RAP)、肺动脉压(PAP)、中心静脉压(CVP)、心率(Hr)。结果休克期实施有创心功能监测是安全的,无一例发生并发症,15例病人均平衡渡过休克期。结论大面积烧伤休克期实施有创心功能监测对指导复苏具有重要意义。     

严重烧伤患者休克期血流动力学监测及护理

总结血流动力学监测在５２例大面积烧伤患者休克期补液及休克期切痂中的护理经验。５２例患者均在入院后立即置入Ｓｗａｎ－Ｇａｎｚ漂浮导管,监测烧伤后血流动力学指标变化,指导休克期复苏及手术切痂。在监测指导下实施快速复苏,所有患者在烧伤后２４ｈ各项血流动力学指标恢复正常,无一例出现并发症。烧伤休克期实施有创血流动力学监测对指导复苏具有重要意义。只要进行精心护理,实施Ｓｗａｎ—Ｇａｎｚ导管监测是安全可靠的。     

每博量变异、血管外肺水指数在烧伤机械通气患者液体复苏临床指导意义

目的探讨每博量变异(SVV)、血管外肺水指数(EVLWI)在烧伤机械通气患者液体复苏中的临床指导意义。方法选取2015年3月~2017年3月我院收治的68例大面积烧伤急诊气管切开机械通气患者。按其是否采用PiCCO监测分为治疗组30例和对照组38例。其中观察组依据患者有创血压、每博量变异(SVV)、血管外肺水指数(EVLWI)、心率、每小时尿量等监测指标指导液体复苏;对照组依据有创动脉压、中心静脉压(CVP)、心率、每小时尿量等监测指标指导液体复苏;观察两组患者休克期内各个时间点(6h、12h、24h、36h、48h)血流动力学指标、血气分析指标、休克期第1个24h、第2个24h补液总量;两组患者入院72h后肺水肿、胸腔积液发生率。结果观察组第1个24h、第2个24h液体补充总量与对照组比较,差异显著(P0.05);观察组入院72h后肺水肿发生率显著少于对照组,差异有统计学意义(P0.05)。结论每博变异、血管外肺水指数可有效监测烧伤机械通气患者休克期液体复苏过程中心脏及机体液体负荷情况,减少因机械通气液体复苏时胸腔内压对CVP的影响,保证各个脏器有效灌注,减轻肺水肿的发生率。     

大面积烧伤休克复苏42例体会

目的:探讨近年来大面积烧伤患者休克期液体复苏的有效性.方法:根据液体复苏后的各项复苏指标.对2004年9月至2009年9月收治的42例大面积烧伤患者,区分出烧伤休克期复苏平稳组与复苏不平稳组.观察伤后实际实行复苏的时间、复苏采用的基本公式、实际输入的液体情况.监测血压、心率、每小时尿量,并对各脏器功能进行保护.结果:5年期间的42例大面积烧伤患者中,重度烧伤27例,特重度烧伤15例,38例平稳度过休克期,并发症发生率15%,4例复苏的指标前期不满意后转稳定,属于重度烧伤2例,特重度烧伤2例,并发症发生率60%.其中1例伤后88d呼吸衰竭死亡,余41例患者均康复出院.结论:目前大面积烧伤患者基本能度过休克期,但因各种原因还未能做到均平稳过渡;平稳度过烧伤休克期,对降低大面积烧伤患者的并发症及提高治愈率有一定的意义与价值.     

烧伤患者休克期切痂的血流动力学变化

目的：探讨烧伤患者临床休克期进行切痂的安全性及可行性。方法：５０例大面积烧伤患者随机分为研究组和对照组。研究组按照血流动力学监测结果进行复苏,血流动力学平稳后４８小时内行首次切痂术;对照组用传统方法复苏,３～５日后行切痂术。结果：２１例患者〔烧伤体表总面积（ＴＢＳＡ）６２．８％±１２．６％,Ⅲ度烧伤面积３７．３％±１８．７％〕进入研究组,伤后（２６±１５）小时行切痂术。第１和第２个２４小时输液量高于标准计算公式约３０％以上。血流动力学监测显示,术后４８小时心脏指数（ＣＩ）明显高于术前〔（７．９±２．２）Ｌ·ｍｉｎ－１·ｍ－２比（４．４±１．２）Ｌ·ｍｉｎ－１·ｍ－２,Ｐ＜０．０１〕,其主要原因是由于每搏指数的改善所致,二者相关密切（ｒ＝０．８９,Ｐ＜０．０１）。与对照组比较,休克期切痂具有消灭创面早、后期并发症少和病程短等优点。结论：对大面积烧伤患者在血流动力学监测指导下进行复苏,选择性地实施休克期切痂是安全可行的。     

大面积烧伤休克期切痂的手术配合

目的 提高大面积深度烧伤休克期切痂植皮的安全性。方法 22例患者休克期切痂术中通过有创动脉压、中心静脉压、血氧饱和度、每小时尿量等综合指标监测下进行静脉补液等措施。结果 绝大多数患者手术过程中病情稳定，尿量满意，各监测指标在预定范围内。结论 术前建立2～3条静脉通路，术中护理人员合理分工，根据需要增加巡回器械护士等，有利于大面积烧伤休克期切痂手术。     

提高大面积烧伤休克期患者急诊入院液体复苏规范率之护理专案

目的探讨提高大面积烧伤休克期患者急诊入院液体复苏规范率的方法。方法通过制定并使用"大面积烧伤患者休克期液体复苏流程表"、烧伤休克期液体计算程序及液体余量尺(余量表),对大面积烧伤休克期患者急诊入院液体复苏流程进行系统规范,指引护理人员严格执行烧伤休克期患者液体复苏流程,掌握复苏观察要点。结果大面积烧伤患者急诊入院液体复苏规范率由69%上升至91%,患者入院3 h病情预警分值下降率(复苏成功率)由27%上升至47%,差异均有统计学意义(P0.05)。结论提高大面积烧伤休克期患者急诊入院液体复苏规范率之护理专案的应用,能使患者平稳渡过烧伤休克期,降低烧伤休克发生率及病死率,减少并发症,提高烧伤患者抢救成功率。     

全心舒张末容量作为判定心脏前负荷指标在犬失血性休克模型中的研究

目的 评估通过热稀释法测量全心舒张末容量作为心脏前负荷指标的准确性和实用性。方法 通过右心漂浮导管和脉搏诱导持续心输出量测量法（PICCO）在20只犬失血性休克模型制作前后，分别给予生理盐水（NS）、贺斯溶液（HES）、高渗盐溶液（HS）以及高渗高张溶液（HSS）对失血性休克模型进行容量复苏，测量容量复苏前后血液动力学，比较全心舒张末容量（GEDV）、中心静脉压（CVP）、肺动脉楔压（PAWP）在判定前负荷中的作用。结果 容量复苏前后血液动力学指标有显著变化（P〈0．05），全心舒张末容量指数（GEDVI）变化与每搏输出指数（SVI）和心输出量指数（CI）的变化呈正相关。中心静脉压和肺动脉楔压的变化与每搏输出指数（SVI）无关。结论 在失血性休克犬模型中，与压力指标（中心静脉压、肺动脉楔压）相比较，全心舒张末容量（GEDV）能够更好地反映心脏前负荷。     

烧伤复苏时心排血量、每搏量、中心静脉压、腹内压和总循环血容量的关系

德国科研人员进行了一项18个月的研究，旨在观察严重烧伤休克复苏治疗时，心排血指数（CI）、每搏量指数（SVI）、中心静脉压（CVP）、腹内压（IAP）及总循环血容量指数（TBVI）之间的相关性。该研究纳入16例平均烧伤面积为46％总体表面积（TBSA，26％～67％TBSA）、平均烧伤严重度指数为8．9（7．0～11．0）的烧伤患者，进行为期18个月的前瞻性研究。利用COLDZ-021系统（德国慕尼黑Pulsion医疗系统）测量CI、SVI和TBVI，烧伤后4d内测量234～278组数据，分析其相关性。分析结果显示：     

大面积烧伤病人应用有创动脉血压监测的护理

目的总结大面积烧伤病人应用有创动脉血压监测与并发症的护理。方法对2007年1月～2008年11月大面积烧伤病人在休克期、麻醉、手术中及术后监测、重症抢救治疗过程中应用动脉穿刺置管,连接压力换能器进行有创动脉血压监测。结果本组病例在进行有创动脉血压监测过程中未出现脱管、堵塞,无感染、血栓、气栓、血肿、肢体远端局部坏死等并发症。结论大面积烧伤病人在休克期、麻醉手术、术后监测及重症抢救治疗中,应用有创动脉血压监测能及时、连续、准确可靠地反映患者的血流动力学情况,为指导休克期补液、抢救治疗及在手术过程中提供有效、及时、准确的动态血压信息。     

大面积烧伤创面深度与补液量的关系临床资料分析

目的探讨烧伤深度与早期补液量的关系。方法从我科4年收治的32例大面积烧伤中选取了21例入院时无特殊并发症病例早期液体复苏临床资料进行回顾性总结。本组病例平均烧伤面积81．3％，平均深度烧伤面积57．6％，开始液体复苏最短为伤后1．5h，最长为伤后6h。以平均心率100次／min，平均尿量80ml／h为输液调控基本指标。结果伤后第1天平均晶，胶体补液量每公斤体重每1％烧伤面积2．19ml，基础液体量（成人）平均4662ml／d。伤后第2天平均晶、胶体补液量每公斤体重每1％烧伤面积1．40ml；深度烧伤占比例越大，晶胶体补液量越多。21例患者有2例分别于伤后第1天和第3天发生DIC，1例伤后第3天发生高钠血症，其余全部平稳度过休克期。除1例伤后6d自动出院外，其他患者均痊愈出院，平均住院天数58d．结论大面积烧伤早期补液不仅与烧伤面积有关，而且与烧伤深度关系密切，浅度烧伤与深度烧伤对补液的需求存在较大差异。传统烧伤补液公式仅以烧伤面积为依据，实有缺陷，建议进行改进修定。     

烧伤病人血流变性动态改变与体液复苏关系的研究

本文通过对２３８例烧伤住院患者按烧伤轻重程度的不同，系统探讨 其伤后不同阶段血液流变学的动态变化规律及其与体液复苏的关系，进一步明确 烧伤后贫血的变化规律及其与血流变学的关系，从而为烧伤休克的体液复苏和烧 伤后贫血的中医中药治疗提供新的监测依据，开辟新的途径。     

The methamphetamine burn patient

Early aggressive fluid resuscitation has significantly decreased the morbidity and mortality associated with volume losses from large burns. Although most patients are adequately resuscitated using the Parkland formula, we noted increased fluid requirements for shock resuscitation in patients involved in methamphetamine laboratory explosions. Because predominant users are young healthy individuals in their 20s and 30s, we had not anticipated burn shock resuscitation failures in this patient group. We reviewed our experience with burn patients with documented methamphetamine use to determine whether this patient group presents new dilemmas to the burn surgeon. A 2-year retrospective study of 30 patients (15 methamphetamine users, 15 controls) revealed that the methamphetamine burn patient requires two to three times the standard Parkland formula resuscitation. In this study, methamphetamine burns larger than 40% TBSA had a 100% mortality.     

血浆代用品血定安应用于烧伤休克复苏的临床研究

目的 :验证血浆代用品 (血定安 )在烧伤休克液体复苏中的临床疗效。方法 :2 0例烧伤总体表面积( TBSA)大于 40 %且因延迟复苏导致休克的烧伤患者 ,随机分为血定安复苏组 (血定安组 ,n=11)和血浆复苏组 (血浆组 ,n=9)进行复苏 ,观察休克期心排血量 ( CO)、氧供给 ( DO2 )、血细胞比容、血液黏度、血浆黏度、乳酸( L A)含量及碱缺失 ( BD)等血流动力学、血液流变学及氧代谢指标的变化。结果 :快速补液 2 h后 ,CO和 DO2显著升高 ( P<0 .0 5或 P<0 .0 1) ,血细胞比容、血液黏度、血浆黏度、L A和动脉血 BD显著下降 ( P<0 .0 5或P<0 .0 1)。两组间比较 ,伤后 2 4h内血定安组补液后血浆黏度显著低于血浆组 ( P均 <0 .0 5 ) ,其余指标无显著性差异 ( P均 >0 .0 5 )。结论 :在烧伤后休克复苏中 ,血浆代用品血定安与血浆的疗效相近 ,可以在烧伤休克早期救治中广泛应用。     

The 2003 Carl A Moyer Award: real-time metabolic monitors, ischemia-reperfusion, titration endpoints, and ultraprecise burn resuscitation

Real-time metabolic monitoring of varied vascular beds provides the raw data necessary to conduct ultraprecise burn shock resuscitation based on second-by-second assessment of regional tissue perfusion. It also illustrates shortcomings of current clinical practices. Arterial base deficit was continuously monitored during 11 clinical resuscitations of patients suffering burn shock using a Paratrend monitor. Separately, in a 30% TBSA rat burn model (N = 70), three Paratrend monitors simultaneously recorded arterial blood gas and tissue pCO2 of the burn wound and colonic mucosa during resuscitation at 0, 2, 4, 6, and 8 ml/kg/%TBSA. Paratrend data were analyzed in conjunction with previously reported laser Doppler images of actual burn wound capillary perfusion. With current clinical therapy, continuous monitoring of arterial base deficit revealed repetitive cycles of resolution/worsening/resolution during burn shock resuscitation. In the rat model, tissue pCO2 in both burn wounds and splanchnic circulation differed depending on the rate of fluid resuscitation (P <.01 between sham and 0 ml/kg/%TBSA and between 2 ml/kg/%TBSA and 4 ml/kg/%TBSA). Burn wound pCO2 values correlated well with laser Doppler determination of actual capillary perfusion (rho = -.48, P <.01). The following conclusions were reached: 1). Gratuitous and repetitive ischemia-reperfusion-ischemia cycles plague current clinical therapy as demonstrated by numerous "false starts" in the resolution of arterial base deficit; 2). in a rat model, real-time monitoring of burn wound and splanchnic pCO2 demonstrate a dose-response relationship with rate of fluid administration; and 3). burn wound and splanchnic pCO2 are highly correlated with direct measurement of burn wound capillary perfusion by laser Doppler imager. Either technique can serve as a resuscitation endpoint for real-time feedback-controlled ultraprecise resuscitation.     

Rationale,design and performance of a clinical trial to investigate interferon-gamma (imukin) in the prophylactic treatment of severe burns-related infections

Recent advances in resuscitation therapy have increased the survival rate of patients with severe burns in the burn shock phase. Infectious complications represent the major cause of death in patients with extensive burns, however, in spite of the application of early and aggressive interventions. Extensive burn injury causes profound alterations in various essential elements of the normal host immune response and the main aim of treatment after resuscitation is to maintain or even improve host resistance. The positive anti-infective effects of interferon (IFN)-gamma observed in animal models and in clinical studies, for example in chronic granulomatous disease, provided the rationale for a study to investigate its use in patients with severe burns. A study was therefore designed to determine the efficacy and tolerance of IFN-gamma in preventing death related to infection in patients with severe burn injury who are at risk of infection. In order to avoid unnecessary risk for patients and reduce the cost, a sequential design was chosen. The primary endpoint was reviewed in a group sequential manner after every 60 patients through an independent monitoring board. The study was a randomised, double-blind, Phase III multi-centre trial, conducted at 23 European Burn Centres. An interval censored survival time approach was taken, using information collected at days 8, 15, 30, 60, and 90. The trial is still blinded, but the rationale for conducting the study and its design are discussed.     

Usefulness of warm fluid in acute burn resuscitation: an experimental study in dogs

Hypothermia is a common complication in patients with extensive burns, receiving massive volumes of fluid for resuscitation at ambient temperature. It is therefore important to maintain the body temperature of patients with extensive burns. The present study was performed to evaluate the usefulness of warm fluid for burn injury resuscitation. Ten dogs were used in this study. Full-thickness burns, involving 40% of the body surface, were generated in the backs of the animals. In the control group (n = 5), the fluid temperature was maintained at about 23 degrees C, while in other group (n = 5), the temperature of the fluid was maintained at 39 degrees C with a warming device. Cardiac output and urinary output were measured in both groups for up to 24 hours. The cardiac output decreased in all animals during the first two hours following injury. The cardiac dynamics remained depressed in the control group. By contrast, in animals treated with warm fluid, the cardiac output returned to the baseline level within 4 hours of resuscitative measures and then decreased slightly for the subsequent 20 hours. The urinary output was better in animals treated with warm fluid, indicating the improved hemodynamic state in these animals. These results suggested that the hemodynamic state in acute burn shock was ameliorated by the use of warm fluid. Therefore, warmed fluid resuscitation might be useful to perform immediate excision and grafting for the patients with extensive burns in acute burn shock.     

Plasma for burn shock resuscitation: is it time to go back to the future?

Patients with burn shock can be challenging to resuscitate. Burn shock produces a variety of physiologic derangements: Patients are hypovolemic from volume loss, have a increased systemic vascular resistance, and may have a depressed cardiac output depending on the extent of the thermal injury. Additionally, the burn wound produces a significant inflammatory cascade of events that contributes to the shock state. Fluid resuscitation is foundational for the initial treatment of burn shock. Typical resuscitation is with intravenous lactated Ringer's in accordance with well‐established formulas based on burn wound size. In the past century, as therapies to treat thermal injuries were being developed, plasma was the fluid used for burn resuscitation; in fact, plasma was used in World War II and throughout the 1950s and 1960s. Plasma was abandoned because of infectious risks and complications. Despite huge strides in transfusion medicine and the increased safety of blood products, plasma has never been readopted for burn resuscitation. Over the past 15 years, there has been a paradigm shift in trauma resuscitation: Less crystalloid and more blood products are used; this strategy has demonstrated improved outcomes. Plasma is a physiologic fluid that stabilizes the endothelium. The endotheliopathy of trauma has been described and is mitigated by transfusion strategies with a 1:1 ratio of RBCs to plasma. Thermal injury also results in endothelial dysfunction: the endotheliopathy of burns. Plasma is likely a better resuscitation fluid for patients with significant burn wounds because of its capability to restore intravascular volume status and treat the endotheliopathy of burns.     

严重烧伤患者实施有创动脉血压监测

目的：为实施烧伤休克期液体复苏多指标监测，创造条件进行有创血压监测，并观察其临床应用的可行性及实用价值。方法：选择19例特重、4例重度烧伤患者桡动脉15次、足背动脉12次、股动脉3次、肱动脉5次，进行动脉穿刺、测压。通过观察动脉搏动波形及血压数值，对患者血压实行动态监护，并与同体无创血压对比。结果：有创血压的监测可连续监测血压数值及变化。有创动脉压较无创血压高5～20mmHg，但与无创血压的变化同步，相关性较好。结论：有创动脉压监测因可显示动脉波形和数值的动态变化，能及时发现患者的病情变化，灵敏度大于无创血压监测，在严重烧伤患者监测中具有重要的意义。