脉搏轮廓心排血量监测技术指导大面积烧伤休克期补液的临床意义

蒋南红; 王德运; 李凤; 谢卫国

doi:10.3760/cma.j.issn.1009-2587.2019.06.007

脉搏轮廓心排血量监测技术指导大面积烧伤休克期补液的临床意义

doi: 10.3760/cma.j.issn.1009-2587.2019.06.007

武汉大学同仁医院暨武汉市第三医院烧伤科 430060

基金项目:

重大疾病防治科技行动计划（2018-ZX-01S-001）

国家自然科学基金面上项目（81772097）

武汉市临床医学科研项目（WX14B13）

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出版历程
- 收稿日期: 2018-11-23
- 网络出版日期: 2021-10-28
- 刊出日期: 2019-06-20

Clinical significance of pulse contour cardiac output monitoring technology in guiding fluid replacement during shock stage of extensive burn

Department of Buns, Tongren Hospital of Wuhan University & Wuhan Third Hospital, Wuhan 430060, China

摘要

摘要: 目的探讨脉搏轮廓心排血量(PiCCO)监测技术在临床大面积烧伤休克期补液治疗中的指导意义。方法选择2014年1月—2018年12月笔者单位收治的符合入选标准的大面积烧伤患者65例进行前瞻性对照研究。根据患者入院顺序编号，将35例奇数号、30例偶数号患者分别纳入常规补液组(男25例、女10例)和PiCCO监测补液组(男21例、女9例)，其年龄分别为(48±9)、(44±8)岁，均按第三军医大学休克期补液公式进行补液治疗。常规补液组根据中心静脉压、平均动脉压、心率、呼吸频率、尿量及患者的临床症状等休克的一般指标调节补液速度；PiCCO监测补液组行PiCCO监测，在常规补液组监测指标的基础上，根据全心舒张末期容积指数并结合PiCCO的其他相关指标指导补液。比较2组患者伤后8、16、24、32、40、48、56、64、72 h心率及液体正平衡量，伤后48、72 h利尿剂使用量，伤后24、48、72 h补液总量、尿量、血乳酸、血小板计数、血细胞比容，住重症监护病房(ICU)时间，伤后28 d内并发症及死亡的发生情况。对数据行重复测量方差分析、t检验、Bonferroni校正、Mann-Whitney U检验、χ²检验、Fisher确切概率法检验。结果伤后8、16、24、32、40、48、56 h，2组患者心率相近(t＝0.775、1.388、2.511、2.203、1.654、2.303、1.808，P>0.05)；伤后64、72 h，PiCCO监测补液组患者心率明显低于常规补液组(t＝3.229、3.357，P<0.05或P<0.01)。伤后8、16、40、56 h，2组患者液体正平衡量相近(t＝0.768、1.670、2.134、2.791，P>0.05)；伤后24、32、48、64、72 h，PiCCO监测补液组患者液体正平衡量明显少于常规补液组(t＝3.364、4.047、2.930、2.950、2.976，P<0.05或P<0.01)。2组患者伤后48、72 h利尿剂使用量相近(Z＝－0.697、－1.239，P>0.05)。伤后24、48、72 h，PiCCO监测补液组患者补液总量分别为(13 864±4 241)、(9 532±2 272)、(8 480±2 180)mL，明显多于常规补液组的(10 388±2 445)、(8 095±1 720)、(7 059±1 297)mL(t＝－3.970、－2.848、－3.137，P<0.05或P<0.01)。2组患者伤后24 h尿量接近(t＝－1.027，P>0.05)；PiCCO监测补液组患者伤后48、72 h尿量分别为(3 051±702)、(3 202±624)mL，明显多于常规补液组的(2 401±588)、(2 582±624)mL(t＝－4.062、－4.001，P<0.01)。伤后24、48、72 h，PiCCO监测补液组患者血乳酸水平明显低于常规补液组(t＝4.758、6.101、3.938，P<0.01)。伤后24、48 h，PiCCO监测补液组患者血小板计数明显高于常规补液组(t＝－2.853、－2.499，P<0.05)，血细胞比容明显低于常规补液组(t＝2.698、4.167，P<0.05或P<0.01)；伤后72 h，2组患者血小板计数、血细胞比容相近(t＝－1.363、0.476，P>0.05)。PiCCO监测补液组患者住ICU时间明显短于常规补液组(t＝2.184，P<0.05)。伤后28 d内，常规补液组患者并发症发生率明显高于PiCCO监测补液组(P<0.05)，病死率与PiCCO监测补液组相近(P>0.05)。结论 PiCCO监测技术用于大面积烧伤患者补液的监测，能较快纠正休克，减少因补液不当所致各脏器并发症的发生，缩短住ICU时间，对指导烧伤休克的救治具有重要意义。
- 烧伤 /
- 休克 /
- 乳酸 /
- 血小板 /
- 血细胞比容 /
- 中心静脉压 /
- 脉搏轮廓心排血量 /
- 全心舒张末期容积指数
Abstract: Objective To explore the guiding significance of pulse contour cardiac output (PiCCO) monitoring technology in the treatment of fluid replacement during shock stage of extensive burn in clinic. Methods Sixty-five patients with extensive burn hospitalized in our unit from January 2014 to December 2018, conforming to the inclusion criteria, were recruited to conduct a prospective controlled research. According to the order of admission, 35 odd-numbered patients and 30 even-numbered patients were enrolled in routine rehydration group (25 males and 10 females) and PiCCO monitoring rehydration group (21 males and 9 females) respectively, with the age of (48±9) and (44±8) years respectively. All patients of the two groups were rehydrated according to the rehydration formula of the Third Military Medical University during shock stage. The rehydration speed was adjusted in routine rehydration group according to the general indexes of shock such as central venous pressure, mean arterial pressure, heart rate, respiratory rate, urine volume, and clinical symptoms of patients. PiCCO monitoring was performed in patients of PiCCO monitoring rehydration group, and the global end-diastolic volume index combined with the other relevant indicators of PiCCO were used to guide rehydration on the basis of the monitoring indicators of routine rehydration group. The heart rates and positive fluid balance volumes at post injury hour (PIH) 8, 16, 24, 32, 40, 48, 56, 64, and 72, the diuretic dosage at PIH 48 and 72, the total fluid replacement volumes, urine volumes, blood lactic acid, platelet count, and hematocrit at PIH 24, 48, and 72, the length of intensive care unit (ICU) stay, and the incidence of complications and death within 28 days after injury were compared between patients in the two groups. Data were processed with analysis of variance for repeated measurement, t test, Bonferroni correction, Mann-Whitney U test, chi-square test, and Fisher′s exact probability test. Results The heart rates of patients in the two groups were similar at PIH 8, 16, 24, 32, 40, 48, and 56 (t=0.775, 1.388, 2.511, 2.203, 1.654, 2.303, 1.808, P>0.05), and the heart rates of patients in PiCCO monitoring rehydration group at PIH 64 and 72 were obviously lower than those of routine rehydration group (t=3.229, 3.357, P<0.05 or P<0.01). The positive fluid balance volumes of patients in the two groups were similar at PIH 8, 16, 40, and 56 (t=0.768, 1.670, 2.134, 2.791, P>0.05), and the positive fluid balance volumes of patients in PiCCO monitoring rehydration group at PIH 24, 32, 48, 64, and 72 were obviously less than those of routine rehydration group (t=3.364, 4.047, 2.930, 2.950, 2.976, P<0.05 or P<0.01). The amount of diuretics used by patients in the two groups was similar at PIH 48 and 72 (Z=-0.697, -1.239, P>0.05). The total fluid replacement volumes of patients in PiCCO monitoring rehydration group at PIH 24, 48, and 72 were (13 864±4 241), (9 532±2 272), and (8 480±2 180) mL, respectively, obviously more than those in routine rehydration group [(10 388±2 445), (8 095±1 720), and (7 059±1 297) mL, respectively, t=-3.970, -2.848, -3.137, P<0.05 or P<0.01]. The urine volumes of patients in the two groups at PIH 24 were close (t=-1.027, P>0.05). The urine volumes of patients in PiCCO monitoring rehydration group at PIH 48 and 72 were (3 051±702) and (3 202±624) mL respectively, obviously more than those in routine rehydration group [(2 401±588) and (2 582±624) mL respectively, t=-4.062, -4.001, P<0.01]. The levels of blood lactate acid of patients in PiCCO monitoring rehydration group at PIH 24, 48, and 72 were obviously lower than those in routine rehydration group (t=4.758, 6.101, 3.938, P<0.01). At PIH 24 and 48, the values of the platelet count of patients in PiCCO monitoring rehydration group were obviously higher than those in routine rehydration group (t=-2.853, -2.499, P<0.05), and the values of hematocrit of patients in PiCCO monitoring rehydration group were obviously lower than those in routine rehydration group (t=2.698, 4.167, P<0.05 or P<0.01). Both the platelet count and hematocrit of patients in the two groups were similar at PIH 72 (t=-1.363, 0.476, P>0.05). The length of ICU stay of patients in PiCCO monitoring rehydration group was obviously shorter than that of routine rehydration group (t=2.184, P<0.05). Within 28 days after injury, the incidence of complications of patients in routine rehydration group was obviously higher than that in PiCCO monitoring rehydration group (P<0.05), while the mortality rate of patients in routine rehydration group was similar to that in PiCCO monitoring rehydration group (P>0.05). Conclusions The application of PiCCO monitoring technology in monitoring fluid replacement in patients with extensive burn can quickly correct shock, reduce the occurrence of organ complications caused by improper fluid replacement, and shorten the length of ICU stay, which is of great significance in guiding the treatment of burn shock.
- Burns /
- Shock /
- Lactic acid /
- Blood platelets /
- Hematocrit /
- Central venous pressure /
- Pulse contour cardiac output /
- Global end-diastolic volume index