Effects of continuous goal-directed analgesia on fluid resuscitation of massive burn patients during shock
-
摘要:
目的 探讨持续目标导向性镇痛对大面积烧伤患者休克期液体复苏的影响，为合理优化烧伤休克期患者镇痛方案提供依据。 方法 采用回顾性病例系列研究方法。2015年1月—2020年12月郑州市第一人民医院收治符合入选标准的大面积烧伤患者136例，根据患者休克期是否持续应用舒芬太尼注射液进行静脉镇痛，将患者分为持续镇痛组（68例，平均年龄44岁）和间断镇痛组（68例，平均年龄45岁），2组患者均以男性为主。治疗前和治疗72 h，分别采用急性生理学和慢性健康状况评价Ⅱ（APACHEⅡ）与视觉模拟评分法（VAS）对2组患者病情严重程度与创面疼痛程度进行评分。于伤后第1、2、3个24 h，记录2组患者血细胞比容（HCT）、心率、平均动脉压（MAP）、中心静脉压（CVP）、中心静脉血氧饱和度（ScvO 2）、补液系数、血乳酸值、每小时尿量以及患者治疗过程中有无低血压、恶心、呕吐、眩晕、骨骼肌强直、呼吸抑制、心动过缓、瘙痒、药物成瘾性等不良反应。对数据进行重复测量方差分析、配对样本或独立样本 t检验、Bonferroni校正、 χ 2检验和Mann-Whitney U检验。 结果 治疗前，2组患者APACHEⅡ、VAS评分均接近（ t值分别为-0.67、0.32， P>0.05）；治疗72 h，持续镇痛组患者APACHEⅡ、VAS评分分别为（8.5±2.2）、（2.5±1.6）分，分别明显低于间断镇痛组的（15.2±3.0）、（7.9±2.0）分（ t值分别为-14.94、-17.46， P<0.01）。与治疗前比较，间断镇痛组患者治疗72 h的APACHEⅡ、VAS评分均明显下降（ t值分别为11.35、30.59， P<0.01）；持续镇痛组患者治疗72 h较治疗前的APACHEⅡ、VAS评分变化均与间断镇痛组相似（ t值分别为4.00、4.82， P<0.01）。与间断镇痛组比较，持续镇痛组患者的CVP、HCT、心率、ScvO 2和MAP在伤后第1、2、3个24 h均无明显变化（ t值分别为<0.01、0.12、2.10、1.55、0.03，0.13、0.22、<0.01、0.17、0.49，0.63、0.06、0.04、2.79、2.33， P>0.05）。与伤后第1个24 h比较，间断镇痛组患者的CVP、ScvO 2和MAP在伤后第2、3个24 h均明显升高（ t值分别为-10.10、-9.31、-8.89，-10.81、-4.65、-9.43， P<0.01），心率在伤后第2、3个24 h均明显下降（ t值分别为7.53、7.78， P<0.01），HCT仅在伤后第3个24 h明显减少（ t=15.55， P<0.01）；持续镇痛组患者伤后第2、3个24 h的CVP、ScvO 2、MAP、心率及伤后第3个24 h的HCT较伤后第1个24 h的变化均与间断镇痛组相似（ t值分别为-12.25、-10.24、-8.99、9.42、-8.83、-7.53、-11.57、10.44、12.91， P<0.01）。与间断镇痛组比较，持续镇痛组患者的补液系数仅在伤后第3个24 h明显升高（ t=5.60， P<0.05），血乳酸值在伤后第1、2个24 h均明显降低（ t值分别为4.32、14.52， P<0.05或 P<0.01），每小时尿量在伤后第1、2、3个24 h均显著增多（ t值分别为24.65、13.12、5.63， P<0.05或 P<0.01）。与伤后第1个24 h比较，间断镇痛组患者的补液系数在伤后第2、3个24 h均明显下降（ t值分别为33.98、36.91， P<0.01），血乳酸值在伤后第2、3个24 h均明显下降（ t值分别为8.20、11.68， P<0.01），每小时尿量在伤后第2、3个24 h均明显增多（ t值分别为-3.52、-5.92， P<0.01）；持续镇痛组患者伤后第2、3个24 h较伤后第1个24 h的补液系数（ t值分别为35.64、33.64， P<0.01）、血乳酸值（ t值分别为9.86、12.56， P<0.01）变化与间断镇痛组相似，每小时尿量仅在伤后第3个24 h明显多于伤后第1个24 h（ t=-3.07， P<0.01）。2组患者均较少发生低血压、恶心、呕吐、眩晕、心动过缓、瘙痒等不良反应，无一例患者出现骨骼肌强直、呼吸抑制、药物成瘾性；持续镇痛组患者不良反应发生率与间断镇痛组相似（ χ 2=0.08， P>0.05）。 结论 持续目标导向性镇痛可有效缓解大面积烧伤患者疼痛，改善患者生命体征，且对容量负荷影响较小，可辅助纠正休克期缺血缺氧状态，有助于患者平稳度过休克期。 Abstract:Objective To investigate the effects of continuous goal-directed analgesia on fluid resuscitation during shock stage in patients with massive burns, providing a basis for rational optimization of analgesia protocols in patients with burn shock. Methods A retrospective case series study was conducted. One hundred and thirty-six patients with massive burns who met the inclusion criteria were admitted to Zhengzhou First People's Hospital from January 2015 to December 2020, and the patients were divided into continuous analgesia (CA) group (68 cases,with average age of 44 years old) and intermittent analgesia (IA) group (68 cases,with average age of 45 years old) according to whether sufentanil injection was continuously used for intravenous analgesia during the shock stage. The patients in the 2 groups were predominantly male. Before and at 72 h of treatment, the severity of disease and trauma pain of patients in the 2 groups were scored by the acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) and the visual analogue scale (VAS). Hematocrit, heart rate, mean arterial pressure (MAP), central venous pressure (CVP), oxygen saturation in central venous blood (ScvO 2), rehydration coefficient, blood lactate value, hourly urine output, and the adverse reactions such as hypotension, nausea, vomiting, dizziness, skeletal muscle tonicity, respiratory depression, bradycardia, pruritus, and drug addiction of patients in the 2 groups during the treatment were recorded at the 1 st, 2 nd, and 3 rd 24 h post-injury. Data were statistically analyzed with analysis of variance for repeated measurement, paired or independent sample t test, Bonferroni correction,chi-square test and Mann-Whitney U test. Results Before treatment, APACHE Ⅱ and VAS scores of patients in the 2 groups were close (with tvalues of -0.67 and 0.32, respectively, P>0.05); At 72 h of treatment, APACHE Ⅱ and VAS scores of patients in CA group were 8.5±2.2 and 2.5±1.6, both of which were significantly lower than (15.2±3.0) and (7.9±2.0) of patients in IA group, respectively (with t values of -14.94 and -17.46, respectively, P<0.01). Compared with the pre-treatment period, the APACHE Ⅱ and VAS scores of patients in IA group decreased significantly at 72 h of treatment (with tvalues of 11.35 and 30.59, respectively, P<0.01); the changes in APACHE Ⅱ and VAS scores of patients at 72 h of treatment in comparison with those of patients before treatment in CA group were all similar to those of patients in IA group (with t values of 4.00 and 4.82, respectively, P<0.01). Compared with those of patients in IA group, there were no significant changes in CVP, hematocrit, heart rate, ScvO 2, and MAP of patients in CA group at all three 24 h post-injury (with tvalues of <0.01, 0.12, 2.10, 1.55, 0.03; 0.13, 0.22, <0.01, 0.17, 0.49; 0.63, 0.06, 0.04, 2.79, and 2.33, respectively, P>0.05). Compared with those of patients in IA group at the 1 st 24 h post-injury, CVP, ScvO 2 and MAP of patients were significantly higher at the 2 nd and 3 rd 24 h post-injury (with t values of -10.10, -9.31, -8.89; -10.81, -4.65, and -9.43, respectively, P<0.01), and the heart rate of patients was significantly lower at the 2 nd and 3 rd 24 h post-injury (with t values of 7.53 and 7.78, respectively, P<0.01), and the hematocrit of patients decreased significantly only at the 3 rd 24 h post-injury ( t=15.55, P<0.01); the changes of CVP, ScvO 2, MAP and heart rate of patients at the 2 nd and the 3 rd 24 h post-injury, and HCT of patients at the 3 rd 24 h post-injury, in comparison with those of patients at the 1 st 24 h post-injury in CA group were similar to those of patients in IA group (with t values of -12.25, -10.24, -8.99, 9.42, -8.83, -7.53, -11.57, 10.44, and 12.91, respectively, P<0.01). Compared with those of patients in IA group, the rehydration coefficient of patients in CA group was significantly higher only at the 3 rd 24 h post-injury ( t=5.60, P<0.05), blood lactate value of patients in CA group was significantly lower at the 1 st and 2 nd 24 h post-injury (with t values of 4.32 and 14.52, respectively, P<0.05 or P<0.01), the hourly urine output of patients in CA group increased significantly at the 1 st, 2 nd, and 3 rd 24 h post-injury (with t values of 24.65, 13.12, and 5.63, respectively, P<0.05 or P<0.01). Compared with the those of patients at the 1 st 24 h post-injury, the rehydration coefficient of patients in IA group decreased significantly at the 2 nd and the 3 rd 24 h post-injury (with t values of 33.98 and 36.91, respectively, P<0.01), the blood lactate values of patients in IA group decreased significantly at the 2 nd and the 3 rd 24 h post-injury (with t values of 8.20 and 11.68, respectively, P<0.01), and the hourly urine output of patients in IA group was significantly increased at the 2 nd and the 3 rd 24 h post-injury (with t values of -3.52 and -5.92, respectively, P<0.01); the changes of rehydration coefficients and blood lactate values of patients at the 2 nd and the 3 rd 24 h post-injury in comparison with those of patients at the 1 st 24 h post-injury in CA group were similar to those of patients in IA group (with tvalues of 35.64, 33.64, 9.86, and 12.56, respectively, P<0.01), but hourly urine output of patients in CA group increased significantly only at the 3 rd 24 h compared with that of patients at the 1 st 24 h post-injury ( t=-3.07, P<0.01). Adverse reactions such as hypotension, nausea, vomiting, dizziness, bradycardia, and pruritus occurred rarely in patients of the 2 groups, and none of the patients had skeletal muscle tonicity, respiratory depression, or drug addiction. The incidence of adverse reactions of patients in CA group was similar to that in IA group ( χ 2=0.08, P>0.05). Conclusions Continuous goal-directed analgesia can effectively relieve pain and improve vital signs of patients with large burns. Meanwhile it has little impact on volume load, which can assist in correcting ischemia and hypoxia during the shock period and help patients get through the shock period smoothly. -
Key words:
- Burns /
- Shock /
- Pain /
- Goal-directed analgesia /
- Fluid resuscitation
-
参考文献
(26) [1] 种丽双,王震生,韩紫娜,等.不同剂量瑞芬太尼对妇科腹腔镜术后患者痛觉过敏的影响[J].中国医师进修杂志,2015,38(3):185-188.DOI: 10.3760/cma.j.issn.1673-4904.2015.03.009. [2] 周扬,谢创波,屠伟峰.重视围术期目标导向全程镇痛推广与普及[J].麻醉安全与质控,2017,1(2):55-59. [3] 夏建国,肖红,张佳,等.烧伤患者休克期静脉注射氯胺酮和芬太尼镇痛的可行性观察[J].中华烧伤杂志,2004,20(5):307.DOI: 10.3760/cma.j.issn.1009-2587.2004.05.026. [4] 王志斌,伊敬东,徐凯智.舒芬太尼对全麻老年患者苏醒期镇痛效果及血流动力学的影响[J].中国综合临床,2013, 29(1):100-103. DOI: 10.3760/cma.j.issn.1008-6315.2013.01.032. [5] 王鹏,石墩义,马伟,等.限制性液体复苏联合舒芬太尼对创伤失血性休克患者院前急救的影响[J].检验医学与临床,2016,13(5):614-616.DOI: 10.3969/j.issn.1672-9455.2016.05.015. [6] 罗高兴,彭毅志,庄颖,等.烧伤休克期有关补液公式的临床应用与评价[J].中华烧伤杂志,2008,24(4):248-250.DOI: 10.3760/cma.j.issn.1009-2587.2008.04.003. [7] HalgasB,BayC,FosterK.A comparison of injury scoring systems in predicting burn mortality[J].Ann Burns Fire Disasters,2018,31(2):89-93. [8] GandhiM, ThomsonC, LordD, et al. Management of pain in children with burns[J]. Int J Pediatr,2010,2010:825657. DOI: 10.1155/2010/825657. [9] JamesDL, JowzaM. Principles of burn pain management[J]. Clin Plast Surg,2017,44(4):737-747. DOI: 10.1016/j.cps.2017.05.005. [10] DevlinJW,SkrobikY,GélinasC,et al.Executive summary: clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU[J].Crit Care Med,2018,46(9):1532-1548.DOI: 10.1097/CCM.0000000000003259. [11] WallSL,ClarkeDL,AllortoNL.Analgesia protocols for burns dressings: challenges with implementation[J].Burns,2019,45(7):1680-1684.DOI: 10.1016/j.burns.2019.04.012. [12] VincentJL, SakrY, SprungCL, et al. Sepsis occurrence in acutely ill patients investigators. sepsis in european intensive care units: results of the SOAP study[J]. Crit Care Med, 2006,34(2):344-353. DOI: 10.1097/01.ccm.0000194725.48928.3a. [13] MorelJ,SalardM,CastelainC,et al.Haemodynamic consequences of etomidate administration in elective cardiac surgery: a randomized double-blinded study[J].Br J Anaesth,2011,107(4):503-509.DOI: 10.1093/bja/aer169. [14] GillespieRS,SeidelK,SymonsJM.Effect of fluid overload and dose of replacement fluid on survival in hemofiltration[J].Pediatr Nephrol,2004,19(12):1394-1399.DOI: 10.1007/s00467-004-1655-1. [15] 张奕威,苏月南,陈咏佳.慢性阻塞性肺疾病需机械通气患者NT-proBNP水平与APACHEⅡ评分相关性临床分析[J].中国实用医刊,2013,40(16):9-11.DOI: 10.3760/cma.j.issn.1674-4756.2013.16.005. [16] 于洋,李青栋.烧伤休克患者的血流动力学特点及目标导向性镇痛研究进展[J].中华烧伤杂志,2018,34(5):318-320.DOI: 10.3760/cma.j.issn.1009-2587.2018.05.015. [17] 王志勇,冯世海,范宝莉,等.导向性限制性液体管理策略对严重烧伤合并重度吸入性损伤患者的影响[J].中华烧伤杂志,2019,35(7):501-506.DOI: 10.3760/cma.j.issn.1009-2587.2019.07.005. [18] KelmDJ,PerrinJT,Cartin-CebaR,et al. Fluid overload in patients with severe sepsis and septic shock treated with early goal-directed therapy is associated with increased acute need for fluid-related medical interventions and hospital death[J]. Shock, 2015, 43(1):68-73. DOI: 10.1097/SHK.0000000000000268. [19] BouchardJ,SorokoSB,ChertowGM,et al.Fluid accumulation, survival and recovery of kidney function in critically ill patients with acute kidney injury[J].Kidney Int,2009,76(4):422-427.DOI: 10.1038/ki.2009.159. [20] 佘明金,朱文博.大剂量舒芬太尼患者自控镇痛治疗难治性癌痛合并爆发痛:一例报道与文献复习[J].中华疼痛学杂志,2021,17(5):543-546.DOI: 10.3760/cma.j.cn101379-20191226-00108. [21] 花嵘,杨永圣,姚爱明,等.强化镇痛对急性创伤患者创伤后应激障碍发病的影响[J].中华急诊医学杂志,2021,30(2):217-220.DOI: 10.3760/cma.j.issn.1671-0282.2021.02.015. [22] BarrJ,FraserGL,PuntilloK,et al.Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit[J].Crit Care Med,2013,41(1):263-306.DOI: 10.1097/CCM.0b013e3182783b72. [23] 李如兵,陈茜,张红艳,等.重症烧伤患者休克期镇痛镇静治疗安全性及疗效观察[J].中华烧伤杂志,2018,34(4):197-202.DOI: 10.3760/cma.j.issn.1009-2587.2018.04.002. [24] 郭鹏,刘菊,王刚,等.纳布啡复合舒芬太尼不同剂量组合用于腹式子宫切除术后镇痛的观察[J].中国医师进修杂志,2019,42(7):603-607.DOI: 10.3760/cma.j.issn.1673-4904.2019.07.008. [25] SchugSA,TingS.Fentanyl formulations in the management of pain: an update[J].Drugs,2017,77(7):747-763.DOI: 10.1007/s40265-017-0727-z. [26] 李一,周军利.脉搏轮廓心排血量监测技术在大面积烧伤患者中的应用研究进展[J].中华烧伤杂志,2018,34(10):737-740.DOI: 10.3760/cma.j.issn.1009-2587.2018.10.018. -
表1 2组大面积烧伤患者一般资料比较
组别 例数 性别［例（%）］ 年龄［岁， M（ Q 1， Q 3）］ 体重［kg， M（ Q 1， Q 3）］ 烧伤总面积［%TBSA， M（ Q 1， Q 3）］ 伤后入院时间［h， M（ Q 1， Q 3）］ 烧伤原因［例（%）］ 男 女 热液烫伤 火焰烧伤 间断镇痛组 68 51（75） 17（25） 45（34，56） 69（58，74） 44（36，62） 2（1，3） 10（15） 58（85） 持续镇痛组 68 55（81） 13（19） 44（33，54） 73（66，77） 50（38，71） 2（1，3） 12（18） 56（82） 统计量值 χ 2=0.68 Z=-0.64 Z=-1.90 Z=-1.71 Z=-0.53 χ 2=0.22 P值 0.408 0.524 0.058 0.087 0.596 0.641 注：TBSA为体表总面积 
下载: 导出CSV
表2 2组大面积烧伤患者镇痛治疗前后APACHEⅡ评分和VAS评分比较（分，
组别与时间点 例数 APACHEⅡ评分 VAS 评分 间断镇痛组 68 治疗前 18.2±6.4 9.1±0.8 治疗72 h 15.2±3.0 7.9±2.0 持续镇痛组 68 治疗前 17.4±6.4 9.1±0.8 治疗72 h 8.5±2.2 2.5±1.6 t 1值 -0.67 0.32 P 1值 0.505 0.749 t 2值 -14.94 -17.46 P 2值 <0.001 <0.001 t 3值 11.35 30.59 P 3值 <0.001 <0.001 t 4值 4.00 4.82 P 4值 <0.001 <0.001 注：APACHEⅡ为急性生理学和慢性健康状况评价Ⅱ，VAS为视觉模拟评分法； t 1值、 P 1值， t 2值、 P 2值分别为2组患者治疗前、治疗72 h各指标组间两两比较所得； t 3值、 P 3值， t 4值、 P 4值为分别为间断镇痛组、持续镇痛组患者治疗前、治疗72 h各指标组内两两比较所得
下载: 导出CSV
表3 2组大面积烧伤患者休克期各时间点容量负荷及缺血缺氧指标比较（
组别及伤后时间点 CVP（cmH 2O） HCT 心率（次/min） ScvO 2 MAP（mmHg） 间断镇痛组 第1个24 h 5.5±1.8 0.89±0.15 108±18 0.64±0.08 67±9 第2个24 h 12.2±4.9 0.89±0.16 90±12 0.79±0.08 88±16 第3个24 h 9.4±2.5 0.52±0.11 85±15 0.73±0.12 86±14 持续镇痛组 第1个24 h 5.5±1.7 0.88±0.18 113±17 0.63±0.08 66±7 第2个24 h 12.5±4.4 0.87±0.17 90±11 0.79±0.08 86±15 第3个24 h 9.0±2.9 0.52±0.11 86±15 0.76±0.11 89±15 t 1值 <0.01 0.12 2.10 1.55 0.03 P 1值 0.961 0.727 0.150 0.215 0.866 t 2值 0.13 0.22 <0.01 0.17 0.49 P 2值 0.715 0.640 0.970 0.680 0.484 t 3值 0.63 0.06 0.04 2.79 2.33 P 3值 0.427 0.806 0.845 0.097 0.129 t 4值 -10.10 0.02 7.53 -9.31 -8.89 P 4值 <0.001 0.988 <0.001 <0.001 <0.001 t 5值 -10.81 15.55 7.78 -4.65 -9.43 P 5值 <0.001 <0.001 <0.001 <0.001 <0.001 t 6值 -12.25 0.12 9.42 -10.24 -8.99 P 6值 <0.001 0.906 <0.001 <0.001 <0.001 t 7值 -8.83 12.91 10.44 -7.53 -11.57 P 7值 <0.001 <0.001 <0.001 <0.001 <0.001 注：间断镇痛组、持续镇痛组患者数均为68例；CVP为中心静脉压，HCT为血细胞比容，ScvO 2为中心静脉血氧饱和度，MAP为平均动脉压；1 cmH 2O=0.098 kPa，1 mmHg=0.133 kPa；CVP、HCT、心率、ScvO 2、MAP处理因素主效应， F值分别为<0.01、0.21、1.14、0.11、0.17， P值分别为0.950、0.646、0.288、0.740、0.683；时间因素主效应， F值分别为144.07、247.76、117.64、88.28、110.60， P值分别为<0.001、<0.001、<0.001、<0.001、<0.001；两者交互作用， F值分别为0.34、0.13、0.93、2.41、1.63， P值分别为0.713、0.880、0.396、0.093、0.197； t 1值、 P 1值， t 2值、 P 2值， t 3值、 P 3值分别为组间伤后第1、2、3个24 h各指标比较所得； t 4值、 P 4值， t 5值、 P 5值分别为间断镇痛组组内伤后第2、3个24 h各指标与伤后第1个24 h比较所得， t 6值、 P 6值， t 7值、 P 7值分别为持续镇痛组组内伤后第2、3个24 h各指标与伤后第1个24 h比较所得
下载: 导出CSV
表4 2组大面积烧伤患者休克期各时间点复苏指标比较（
组别及伤后时间点 例数 补液系数（mL·kg -1·%TBSA -1） 血乳酸值（mmol/L） 每小时尿量（mL/h） 间断镇痛组 68 第1个24 h 1.41±0.18 5.0±2.2 44±15 第2个24 h 0.58±0.08 2.6±0.9 54±18 第3个24 h 0.57±0.09 1.9±0.6 63±21 持续镇痛组 68 第1个24 h 1.42±0.18 4.3±1.7 60±21 第2个24 h 0.59±0.10 2.0±0.8 67±24 第3个24 h 0.61±0.09 1.7±0.7 72±21 t 1值 0.06 4.32 24.65 P 1值 0.801 0.040 <0.001 t 2值 0.84 14.52 13.12 P 2值 0.362 <0.001 <0.001 t 3值 5.60 3.62 5.63 P 3值 0.019 0.059 0.019 t 4值 33.98 8.20 -3.52 P 4值 <0.001 <0.001 0.001 t 5值 36.91 11.68 -5.92 P 5值 <0.001 <0.001 <0.001 t 6值 35.64 9.86 -1.74 P 6值 <0.001 <0.001 0.087 t 7值 33.64 12.56 -3.07 P 7值 <0.001 <0.001 0.003 注：TBSA为体表总面积；补液系数、血乳酸值、每小时尿量处理因素主效应， F值分别为2.29、14.02、49.92， P值分别为0.132、<0.001、<0.001；时间因素主效应， F值分别为1 967.83、196.42、18.01， P值分别为<0.001、<0.001、<0.001；两者交互作用， F值分别为0.48、1.35、0.98， P值分别为0.621、0.261、0.378； t 1值、 P 1值， t 2值、 P 2值， t 3值、 P 3值分别为组间伤后第1、2、3个24 h各指标比较所得； t 4值、 P 4值， t 5值、 P 5值分别为间断镇痛组组内伤后第2、3个24 h各指标与伤后第1个24 h比较所得， t 6值、 P 6值， t 7值、 P 7值分别为持续镇痛组组内伤后第2、3个24 h各指标与伤后第1个24 h比较所得
下载: 导出CSV
-
表(4)
计量
- 文章访问数: 314
- HTML全文浏览量: 65
- PDF下载量: 44
- 被引次数: 0
