控制大面积烧伤患者过度液体复苏预防并发症

郇京宁; 黄晓琴

doi:10.3760/cma.j.cn501120-20210813-00281

控制大面积烧伤患者过度液体复苏预防并发症

doi: 10.3760/cma.j.cn501120-20210813-00281

郇京宁^,,
黄晓琴

上海交通大学医学院附属瑞金医院烧伤整形科，上海　　200025

基金项目:

国家自然科学基金面上项目 81772077

国家自然科学基金青年科学基金项目 81801910

详细信息

通讯作者:
郇京宁，Email：jnhuan@sina.com

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出版历程
- 收稿日期: 2021-08-13

Controlling excessive fluid resuscitation in massive burn patients to prevent complications

Huan Jingning^,,
Huang Xiaoqin

Department of Burn and Plastic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China

Funds:

General Program of National Natural Science Foundation of China 81772077

Youth Science Foundation Project of National Natural Science Foundation of China 81801910

More Information

Corresponding author: Huan Jingning, Email: jnhuan@sina.com

摘要

摘要: 大面积烧伤患者过度液体复苏已是烧伤治疗中的常见现象，原因可能与伤后第1个24 h仅用电解质溶液复苏、追求血流动力学指标达到正常水平的目标导向性液体复苏策略等有关。过度液体复苏引起组织水肿是诱发呼吸功能不全、腹腔间室综合征等并发症的重要因素。对于大面积烧伤患者，应该从确定理想的复苏策略、设定合适的复苏目标值、实施复苏液体精细化管理等诸多方面入手，控制过度液体复苏，预防相关并发症。
- 烧伤 /
- 补液疗法 /
- 过度液体复苏 /
- 组织水肿 /
- 并发症
Abstract: Excessive fluid resuscitation in massive burn patients is a common phenomenon in burn management, and the reasons are mostly related with administering resuscitation of crystalloid alone and pursuing a goal-directed resuscitation with targeting normal hemodynamic parameters in the first 24 h post burn. Tissue edema caused by excessive fluid resuscitation is a vital factor that induces complications including respiratory compromise, abdominal compartment syndrome, and so on. Therefore, in order to control excessive fluid resuscitation and prevent its subsequent complications in massive burn patients, it is necessary to determine the optimal resuscitation regime, set appropriate resuscitation endpoints, and implement precise management of fluid resuscitation.
- Burns /
- Fluid therapy /
- Over- resuscitation /
- Tissue edema /
- Complication
所有作者均声明不存在利益冲突

该研究旨在评价腹腔复苏对烧伤合并失血小鼠生存时间的影响。模型制作：将C57BL/6J小鼠背部于90 ℃水浴中浸浴7 s造成30%TBSAⅢ度烫伤，立即腹腔注射生理盐水或腹膜透析液或不补液，然后通过股动脉放血将平均动脉压降至25 mm Hg（1 mmHg=0.133 kPa）并维持30 min，随后在15 min内通过静脉输注乳酸林格液或红细胞和新鲜冰冻血浆体积比1∶1混合液将收缩压恢复至80 mm Hg。上述复苏方案包括不补液联合乳酸林格液、不补液联合红细胞和新鲜冰冻血浆体积比1∶1混合液、生理盐水联合乳酸林格液、生理盐水联合红细胞和新鲜冰冻血浆体积比1∶1混合液、腹膜透析液联合乳酸林格液、腹膜透析液联合红细胞和新鲜冰冻血浆体积比1∶1混合液。结果显示，不补液联合乳酸林格液复苏的烫伤小鼠和不补液联合红细胞和新鲜冰冻血浆1∶1混合液复苏的烫伤小鼠的中位生存时间分别为1.47、2.08 h。烫伤后腹腔注射生理盐水或腹膜透析液可显著延长小鼠生存时间。生理盐水或腹膜透析液联合红细胞和新鲜冰冻血浆1∶1混合液复苏的烫伤小鼠液体需求量少于其他方案复苏烫伤小鼠。与腹腔注射腹膜透析液相比，腹腔注射生理盐水烫伤小鼠的TNF-α和巨噬细胞炎症蛋白1α水平较低，IL-10和肠型脂肪酸结合蛋白水平较高，并能延缓急性肺损伤的进展。

刘兆兴,编译自《Mil Med》, 2020, 185(9/10): e1528-e1535;申传安,审校

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参考文献(40)

[1]	SaffleJR. Fluid creep and over-resuscitation[J]. Crit Care Clin, 2016,32(4):587-598. DOI: 10.1016/j.ccc.2016.06.007.
[2]	PruittBAJr. Protection from excessive resuscitation: "pushing the pendulum back"[J]. J Trauma, 2000, 49(3): 567-568. DOI: 10.1097/00005373-200009000-00030.
[3]	WibbenmeyerL, SevierA, LiaoJL, et al. The impact of opioid administration on resuscitation volumes in thermally injured patients[J]. J Burn Care Res, 2010, 31(1):48-56. DOI: 10.1097/BCR.0b013e3181c7ed30.
[4]	AtiyehBS, DiboSA, IbrahimAE, et al. Acute burn resuscitation and fluid creep: it is time for colloid rehabilitation[J]. Ann Burns Fire Disaters, 2012, 25(2): 59-65.
[5]	杨萌, 戴小华, 郭光华, 等.不同年龄段不同烧伤面积严重烧伤患儿休克期液体复苏策略及疗效评价[J].中华烧伤杂志,2021,37(10):929-936. DOI: 10.3760/cma.j.cn501120-20210408-00119.
[6]	BoehmD, MenkeH.A history of fluid management-from "one size fits all" to an individualized fluid therapy in burn resuscitation[J]. Medicina (Kaunas), 2021,57(2): 187. DOI: 10.3390/medicina57020187.
[7]	GuilabertG, UsúaN, MartínN, et al.Fluid resuscitation management in patients with burns: update[J]. Br J Anaesth,2016, 117(3): 284-296. DOI: 10.1093/bja/aew266.
[8]	HolmC, MayrM, TegelerJ, et al. A clinical randomized study on the effects of invasive monitoring on burn shock resuscitation[J]. Burns, 2004, 30(8): 798-807. DOI: 10.1016/j.burns.2004.06.016.
[9]	CsontosC, FoldiV, FischerT, et al. Arterial thermodilution in burn patients suggests a more rapid fluid administration during early resuscitation[J]. Acta Anaesthesiol Scand, 2008,52(6):742-749. DOI: 10.1111/j.1399-6576.2008.01658.x.
[10]	AboelattaY, AbdelsalamA. Volume overload of fluid resuscitation in acutely burned patients using transpulmonary thermodilution technique[J]. J Burn Care Res, 2013, 34(3):349-354. DOI: 10.1097/BCR.0b013e3182642b32.
[11]	BakZ, SjöbergF, ErikssonO, et al. Hemodynamic changes during resuscitation after burns using the Parkland formula[J]. J Trauma, 2009, 66(2):329-336. DOI: 10.1097/TA.0b013e318165c822.
[12]	ReidRD, JayamahaJ. The use of a cardiac output monitor to guide the initial fluid resuscitation in a patient with burns[J]. Emerg Med J, 2007,24(5): e32. DOI: 10.1136/emj.2006.043349.
[13]	IvyME, AtwehNA, PalmerJ, et al. Intra-abdominal hypertension and abdominal compartment syndrome in burn patients[J]. J Trauma,2000,49(3):387-391. DOI: 10.1097/00005373-200009000-00001.
[14]	KleinMB, HaydenD, ElsonC, et al. The association between fluid administration and outcome following major burn: a multicenter study[J]. Ann Surg, 2007, 245(4):622-628. DOI: 10.1097/01.sla.0000252572.50684.49.
[15]	OdaJ, YamashitaK, InoueT, et al. Resuscitation fluid volume and abdominal compartment syndrome in patients with major burns[J]. Burns, 2006, 32(2): 151-154. DOI: 10.1016/j.burns.2005.08.011.
[16]	StrangSG, Van LieshoutEMM, BreederveldRS, et al. A systematic review on intra-abdominal pressure in severely burned patients[J]. Burns, 2014,40(1): 9-16. DOI: 10.1016/j.burns.2013.07.001.
[17]	MarkellKW, RenzEM, WhiteCE, et al. Abdominal complications after severe burns[J]. J Am Coll Surg,2009,208(5): 940-949. DOI: 10.1016/j.jamcollsurg.2008.12.023.
[18]	BoehmD, ArrasD, SchroederC, et al. Mechanical ventilation as a surrogate for diagnosing the onset of abdominal compartment syndrome (ACS) in severely burned patients (TIRIFIC-study Part Ⅱ)[J]. Burns, 2020, 46(6): 1320-1327. DOI: 10.1016/j.burns.2020.02.005.
[19]	BoehmD, SchröderC, ArrasD, et al. Fluid management as a risk factor for intra-abdominal com partment syndrome in burn patients: a total body surface area-independent multicenter trial part Ⅰ[J]. J Burn Care Res, 2019, 40(4): 500-506. DOI: 10.1093/jbcr/irz053.
[20]	LiY, RenJN, WuXW, et al. Intra-abdominal infection combined with intra-abdominal hypertension aggravates the intestinal mucosal barrier dysfunction[J]. Biosci Rep,2018,38(1):BSR20170931. DOI: 10.1042/BSR20170931.
[21]	ChengJT, WeiZY, LiuX, et al. The role of intestinal mucosa injury induced by intra-abdominal hypertension in the development of abdominal compartment syndrome and multiple organ dysfunction syndrome[J]. Crit Care,2013,17(6):R283.DOI: 10.1186/cc13146.
[22]	LiuNT, RizzoJA, ShieldsBA, et al. Predicting the ability of wounds to heal given any burn size and fluid volume: an analytical approach[J]. J Burn Care Res, 2018,39(5):661-669. DOI: 10.1093/jbcr/iry021.
[23]	O'MaraMS, SlaterH, GoldfarbIW, et al. A prospective, randomized evaluation of intra-abdominal pressures with crystalloid and colloid resuscitation in burn patients[J]. J Trauma, 2005, 58(5): 1011-1018. DOI: 10.1097/01.ta.0000162732.39083.15.
[24]	VlachouE,GoslingP, MoiemenNS. Microalbuminuria: a marker of endothelial dysfunction in thermal injury[J].Burns, 2006, 32(8):1009-1016.DOI: 10.1016/j.burns.2006.02.019.
[25]	PillingerNL, KamP. Endothelial glycocalyx: basic science and clinical implications[J]. Anaesth Intensive Care,2017,45(3):295-307. DOI: 10.1177/0310057X1704500305.
[26]	KozarRA, PengZL, ZhangRZ, et al. Plasma restoration of endothelial glycocalyx in a rodent model of hemorrhagic shock[J].Anesth Analg,2011,112(6):1289-1295. DOI: 10.1213/ANE.0b013e318210385c.
[27]	RehmM, BrueggerD, ChristF, et al. Shedding of the endothelial glycocalyx in patients undergoing major vascular surgery with global and regional ischemia[J]. Circulation, 2007,116(17):1896-1906. DOI: 10.1161/CIRCULATIONAHA.106.684852.
[28]	NieuwdorpM, MeuweseMC, VinkH, et al. The endothelial glycocalyx: a potential barrier between health and vascular disease[J]. Curr Opin Lipidol, 2005,16(5): 507-511.DOI: 10.1097/01.mol.0000181325.08926.9c.
[29]	ZhangCK, GuoF, ChangML, et al. Exosome-delivered syndecan-1 rescues acute lung injury via a FAK/p190RhoGAP/RhoA/ROCK/NF-κB signaling axis and glycocalyx enhancement[J]. Exp Cell Res, 2019,384(1):111596. DOI: 10.1016/j.yexcr.2019.111596.
[30]	MilfordEM, ReadeMC. Resuscitation fluid choices to preserve the endothelial glycocalyx[J]. Crit Care,2019, 23(1): 77.DOI: 10.1186/s13054-019-2369-x.
[31]	RomanowskiKS, PalmieriTL. Pediatric burn resuscitation: past, present, and future[J/OL]. Burns Trauma, 2017, 5:26 [2021-08-13]. https://pubmed.ncbi.nlm.nih.gov/28879205/.DOI: 10.1186/s41038-017-0091-y.
[32]	KirkpatrickAW, BallCG, NickersonD, et al. Intraabdominal hypertension and the abdominal compartment syndrome in burn patients[J]. World J Surg, 2009, 33(6):1142-1149.DOI: 10.1007/s00268-009-9995-4.
[33]	KirkpatrickAW, RobertsDJ, De WaeleJ, et al. Intra-abdominal hypertension and the abdominal compartment syndrome: updated consensus definitions and clinical practice guidelines from the World Society of the Abdominal Compartment Syndrome[J]. Intensive Care Med, 2013, 39(7):1190-1206.DOI: 10.1007/s00134-013-2906-z.
[34]	ArlatiS, StortiE, PradellaV, et al. Decreased fluid volume to reduce organ damage: a new approach to burn shock resuscitation? A preliminary study[J]. Resuscitation,2007,72(3):371-378. DOI: 10.1016/j.resuscitation.2006.07.010.
[35]	SánchezM, García-de-LorenzoA, HerreroE, et al. A protocol for resuscitation of severe burn patients guided by transpulmonary thermodilution and lactate levels: a 3-year prospective cohort study[J]. Crit Care, 2013,17(4): R176.DOI: 10.1186/cc12855.
[36]	AboelattaY, AbdelsalamA. Volume overload of fluid resuscitation in acutely burned patients using transpulmonary thermodilution technique[J]. J Burn Care Res,2013,34(3):349-354. DOI: 10.1097/BCR.0b013e3182642b32.
[37]	BranskiLK, HerndonDN, ByrdJF, et al. Transpulmonary thermodilution for hemodynamic measurements in severely burned children[J]. Crit Care, 2011, 15(2): R118. DOI: 10.1186/cc10147.
[38]	张家平, 向飞, 童大力,等. 限制性液体管理策略对严重烧伤患者早期肺功能影响的对比研究[J].中华烧伤杂志,2012, 28(3):165-169. DOI: 10.3760/cma.j.issn.1009-2587.2012.03.002.
[39]	FloresE, Sánchez-SánchezM, GutierrezC, et al. High dose ascorbic acid during acute resuscitation in critically burn patients[J]. J Burn Care Res, 2022,43(1): 149-155. DOI: 10.1093/jbcr/irab088.
[40]	GholamiB, HaddadWM, BaileyJM, et al. Closed-loop control for fluid resuscitation: recent advances and future challenges[J]. Front Vet Sci, 2021,8:642440. DOI: 10.3389/fvets.2021.642440.