Effects of cardiac support on delayed resuscitation in extensively burned patients with shock
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摘要: 目的 探讨心力扶持对大面积烧伤患者休克延迟复苏的影响。 方法 回顾性分析解放军第一五九医院(以下称笔者单位)2012年1月-2017年1月收治的入院时伴有休克的62例大面积烧伤患者的病历资料,按液体复苏过程中是否应用去乙酰毛花苷和乌司他丁分为心力扶持组(35例)和对照组(27例)。2组患者入院后均以第三军医大学补液公式为基础行常规液体复苏至伤后48 h。心力扶持组患者另将去乙酰毛花苷注射液以首次剂量0.4~0.6 mg加入20 mL的100 g/L葡萄糖注射液中缓慢静脉推注,每6~8小时补充0.2~0.4 mg,每日总量不超过1.6 mg;将注射用乌司他丁1×105 U加入到100 mL的50 g/L葡萄糖注射液中缓慢静脉滴注,每12小时1次。2组患者其他治疗方法均按笔者单位常规方案执行。统计2组患者如下指标。(1)伤后48 h内的每小时尿量和伤后48 h的心率、平均动脉压(MAP)、中心静脉压(CVP)、血乳酸、剩余碱、血细胞比容(HCT)和血白蛋白。(2)伤后第1、2个24 h电解质、胶体输入量以及伤后48 h内总补液量。(3)伤后48 h的肌酸激酶(CK)、心肌型肌酸激酶同工酶(CK-MB)、乳酸脱氢酶(LDH)、总胆汁酸(TBA)、丙氨酸转氨酶(ALT)、天冬氨酸转氨酶(AST)、β2微球蛋白(β2-MG)、尿素氮、肌酐。(4)患者心力衰竭、肺水肿、胸腔积液、腹腔积液、肾功能衰竭、脓毒症及死亡情况。对数据行独立样本
t 检验、Fisher确切概率法检验、Pearsonχ 2检验、连续校正χ 2检验。 结果 (1)2组患者伤后48 h内的尿量和伤后48 h的心率、MAP、CVP、HCT、血白蛋白等指标差异无统计学意义(t =0.150、0.488、0.805、0.562、1.742、0.696,P >0.05);心力扶持组患者血乳酸和剩余碱水平分别为(4.2±2.2)、(-4.3±2.0)mmol/L,明显优于对照组的(5.9±1.7)、(-6.0±3.1)mmol/L(t =3.249、2.480,P <0.05或P <0.01)。(2)2组患者仅伤后第1个24 h胶体输入量无明显差异(t =0.642,P >0.05),心力扶持组患者伤后第1个24 h电解质输入量、第2个24 h电解质和胶体输入量以及伤后48 h内总补液量均明显少于对照组(t =2.703、4.223、3.437、2.515,P <0.05或P <0.01)。(3)心力扶持组患者伤后48 h CK、CK-MB、LDH、TBA、ALT、AST、β2-MG、尿素氮、肌酐水平均明显低于对照组(t =3.066、3.963、3.225、2.943、2.431、3.084、4.052、2.915、3.353,P <0.05或P <0.01)。(4)心力扶持组患者的胸腔积液、腹腔积液发生率及病死率均低于对照组(χ 2=5.514、6.984、4.798,P <0.05或P <0.01),2组患者心力衰竭、肺水肿、肾功能衰竭及脓毒症等发生情况差异无统计学意义[χ 2=1.314(脓毒症),P >0.05]。 结论 大面积烧伤患者休克延迟复苏的同时采取强心和保护心肌措施,有助于改善细胞组织缺氧代谢、减少补液量、减轻脏器缺血缺氧性损害,为降低远期并发症发生率和病死率奠定基础。Abstract: Objective To explore the effects of cardiac support on delayed resuscitation in extensively burned patients with shock. Methods Clinical data of 62 extensively burned patients with shock on admission, admitted to the 159th Hospital of PLA (hereinafter referred to as our hospital) from January 2012 to January 2017, were retrospectively analyzed. They were divided into cardiac support group (n =35) and control group (n =27) according to the use of deslanoside and ulinastatin. All patients were treated with routine fluid resuscitation based on the formula of the Third Military Medical University till post injury hour (PIH) 48. Patients in cardiac support group were given slow intravenous injection of deslanoside which was added in 20 mL 100 g/L glucose injection with first dose of 0.4 to 0.6 mg, 0.2 to 0.4 mg per 6 to 8 h, no more than 1.6 mg daily, and slow intravenous injection of 1×105U ulinastatin which was added in 100 mL 50 g/L glucose injection, once per 12 h. Other treatments of patients in the two groups followed the same conventional procedures of our hospital. The following data of the two groups of patients were collected. (1) The data of urine volume per hour within PIH 48, heart rate, mean arterial pressure (MAP), central venous pressure (CVP), blood lactic acid, base excess, hematocrit, and albumin at PIH 48 were recorded. (2) The input volumes of electrolyte, colloid within the first and second 24 hours post burn and the total fluid input volumes within PIH 48 were recorded. (3) The data of creatine kinase, creatine kinase isoenzyme-MB, lactate dehydrogenase, total bile acid, alanine aminotransferase, aspartate aminotransferase, β2-microglobulin, urea nitrogen, and creatinine at PIH 48 were recorded. (4) The complications including cardiac failure, pulmonary edema, pleural effusion, seroperitoneum, renal failure, sepsis, and death were also recorded. Data were processed with independent samplet test, Fisher′s exact test, Pearson chi-square test, or continuous correction chi-square test. Results (1) There were no statistically significant differences in urine volume within PIH 48, heart rate, MAP, CVP, hematocrit, or albumin at PIH 48 between the patients of two groups (t =0.150, 0.488, 0.805, 0.562, 1.742, 0.696,P >0.05). While the levels of blood lactic acid and base excess were respectively (4.2±2.2) and (-4.3±2.0) mmol/L in patients of cardiac support group, which were significantly better than (5.9±1.7) and (-6.0±3.1) mmol/L in patients of control group (t =3.249, 2.480,P <0.05 orP <0.01). (2) There was no statistically significant difference in input volume of colloid within the first 24 hours post burn between the patients of two groups (t =0.642,P >0.05). The input volume of electrolyte within the first 24 hours post burn, the input volumes of electrolyte and colloid within the second 24 hours post burn, and the total fluid input volume within PIH 48 of patients in cardiac support group were significantly less than those in control group (t =2.703, 4.223, 3.437, 2.515,P <0.05 orP <0.01). (3) The levels of creatine kinase, creatine kinase isoenzyme-MB, lactate dehydrogenase, total bile acid, alanine aminotransferase, aspartate aminotransferase, β2-microglobulin, urea nitrogen, and creatinine of patients in cardiac support group at PIH 48 were significantly lower than those in control group (t =3.066, 3.963, 3.225, 2.943, 2.431, 3.084, 4.052, 2.915, 3.353,P <0.05 orP <0.01). (4) The occurrences of pleural effusion and seroperitoneum and mortality of patients in cardiac support group were significantly lower than those in control group (χ 2=5.514, 6.984, 4.798,P <0.05 orP <0.01). There were no statistically significant differences in cardiac failure, pulmonary edema, renal failure, and sepsis between the patients of two groups [χ 2=1.314 (sepsis),P >0.05]. Conclusions The cardiotonic and cardiac protection treatments in delayed resuscitation of extensively burned patients with shock contribute to improving the cellular anonic metabolism, reducing the volume of fluid resuscitation, and mitigating the ischemic and hypoxic damage to organs, so as to lay foundation for decreasing further complication incidences and mortality.-
Key words:
- Burns /
- Shock /
- Fluid therapy /
- Delayed resuscitation /
- Myocardial damage /
- Deslanoside /
- Ulinastatin
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