延迟快速复苏对烧伤休克循环影响的临床研究

目的探讨在烧伤延迟复苏情况下,如何迅速纠正休克.方法通过对20例烧伤面积大于40%TBSA、因延迟复苏导致休克的患者,进行延迟快速复苏.观察休克期液体出入量、动咏压(BP)、肺动脉压(PAP)、肺动脉楔状压(PAWP)、中心静脉压(CVP)、心输出量(CO)、肺血管阻力(PVR)、外周血管阻力(SVR)、氧供应(DO2)、氧消耗(VO2)、氧摄取率(O2ext)、乳酸(LA)及碱缺失(BD)等血流动力学和氧代谢指标的变化.结果快速补液后2h内输入液体占“第一个24h公式计算量”的(38.8±6.1)%,如果加上院外补液量则占“第一个24h公式计算量”的(48.3±5.0)%.第一个24h实际补入量占“第一个24h公式计算量”的(131.4±14.3)%;第二个24h实际补入量占“第二个24h公式计算量”的(103.2±7.2)%.快速补液后,尿量大幅增加,CO显著升高,DO2增强,SVR、LA、BD大幅下降,PVR虽大幅升高,但PAWP、PAP和CVP并未超过正常.结论在严密血流动力学监护下,烧伤后延迟复苏初期加快补液速度是可行且有益的,烧伤休克的延迟复苏需要显著增加补液量.指导休克延迟快速复苏应以监护心输出量及PAP、PAWP、CVP等血流动力学指标为主,辅以血中LA、BD水平及尿量变化等临床指标的监测.

A clinical study on the effects of delayed rapid fluid resuscitation on the blood circulation during postburn shock stage

OBJECTIVE: To explore the protocol for the quick correction of postburn shock in case of delayed resuscitation. METHODS: Twenty burn patients inflicted with 40% or bigger TBSA burn, and who were in shock due to delayed admission to hospital, were enrolled in the study. The patients were treated by delayed rapid fluid resuscitation. The amount of infused fluid and urine output was observed. The indices of hemodynamics and oxygen metabolism, i.e. arterial blood pressure (BP), pulmonary arterial pressure (PAP), pulmonary arterial wedge pressure (PAWP), central venous pressure(CVP), cardiac output (CO), pulmonary vascular resistance (PVR), systemic vascular resistance (SVR), oxygen delivery (DO2), oxygen consumption (VO2), oxygen extraction (O2ext), lactic acid (LA) and base deficit (BD) were monitored at the shock stage(1 approximately 48 PBHs). RESULTS: The amount of rapid fluid infusion within 2 hours after admission accounted for (38.8 +/- 6.1)% of the amount calculated with the formula (The Third Military Medical University burn shock fluid infusion formula) for the 1st 24 PBHs. When the amount of prehospital infusion was added, the amount would be (48.3 +/- 5.0)% of the amount for the 1st 24 PBHs. The real amount of the infusion for the 1st 24 PBHs was (31.4 +/- 14.3)% more than that of the formula amount, and the real infused fluid amount for the 2nd 24 PBHs was (3.2 +/- 7.2)% more than that of the formula amount. After rapid fluid infusion, there exhibited remarkable increase in urine output, CO and DO2 with evident decrease in SVR, LA and BD. Furthermore, PAWP, PAP and CVP remained within normal range even though PVR increased significantly after rapid fluid infusion. CONCLUSION: In case of shock or compulsory delayed resuscitation, rapid fluid resuscitation during early postburn stage was beneficial with critical hemodynamic monitoring. The amount of delayed rapid fluid infusion was much increased than routine. Hemodynamic indices such as CO, PAP, PAWP and CVP were employed as the guidelines for delayed rapid resuscitation with reference to some clinical indices such as serum LA, blood gas analysis and urine output.