Yang M,Dai XH,Guo GH,et al.Fluid resusstrategy and efficacy evaluation in shock stage in severely burned children with different burn areas in different age groups[J].Chin J Burns,2021,37(10):929-936.DOI: 10.3760/cma.j.cn501120-20210408-00119.
Citation: Tong L,Zhang WF,Han F,et al.Clinical effects of autologous split-thickness skin grafting for prefabricating urethra combined with scrotal flap in repairing middle urethral defect with penile defect[J].Chin J Burns Wounds,2023,39(3):215-220.DOI: 10.3760/cma.j.cn501225-20221021-00465.

Clinical effects of autologous split-thickness skin grafting for prefabricating urethra combined with scrotal flap in repairing middle urethral defect with penile defect

doi: 10.3760/cma.j.cn501225-20221021-00465
Funds:

General Program of National Natural Science Foundation of China 82272268

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  •   Objective   To investigate the clinical effects of autologous split-thickness skin grafting for prefabricating urethra combined with scrotal flap in repairing middle urethral defect with penile defect.   Methods   The retrospective observational study was conducted. Eight male patients (aged 14 to 58 years) with middle urethral defect and penile defect caused by various injuries who met the inclusion criteria were admitted to the First Affiliated Hospital of Air Force Medical University from January 2015 to January 2022. The length of urethral defect was 3 to 5 cm, and the wound area of penile defect after debridement was 5.0 cm×2.5 cm to 7.0 cm×5.5 cm. All the patients underwent autologous split-thickness skin grafting for prefabricating defect urethra in stage Ⅰ, and urethral anastomosis was performed and unilateral scrotal flap was transferred to reconstruct urethra and penis in stage Ⅱ. The area of scrotal flap was 6.0 cm×3.0 cm to 8.0 cm×6.0 cm. The wound in the donor area of skin graft was covered by oil gauze, and the wound of flap donor area was sutured directly. On the 7 th day after the operation of stage Ⅱ, the survival of the flap was observed. In 3 weeks after the operation of stage Ⅱ, the urinary flow rate was measured by the urinary flow rate detector (urinary flow rate >15 mL/s was regarded as unobstructed urination), the urinary fistula and erectile function were observed, and the self-made therapeutic satisfaction questionnaire was used to investigate the therapeutic satisfaction degree of patients. During follow-up, the appearance of the flap recipient area was observed, the Vancouver scar scale (VSS) was used to evaluate the scar situation in the donor areas of skin graft and flap, the urinary flow rate was detected as before, the urethral stricture, urinary fistula, and erectile function were observed, and the therapeutic satisfaction degree of patients was investigated.   Results   On the 7 th day after the operation of stage Ⅱ, the flaps survived completely in 8 patients. In 3 weeks after the operation of stage Ⅱ, the urinary flow rate was 25.3 (18.0, 38.5) mL/s, with unobstructed urination, without urinary fistula and with erectile function, and the score of therapeutic satisfaction degree was 14.3 (14.0, 15.0). During follow-up of 1 to 7 years, the flap recipient area of 8 patients was full in appearance and not swollen, with similar color to the surrounding tissue; the VSS scores of the donor areas of skin graft and flap were 11.5 (10.0, 13.0) and 10.5 (9.3, 12.0), respectively, the urinary flow rate was 24.6 (17.7, 34.1) mL/s, with no urethral stricture, urinary fistula, and erectile dysfunction, and the score of therapeutic satisfaction degree was 13.5 (13.3, 14.8).   Conclusions   Autologous split-thickness skin grafting for prefabricating urethra combined with scrotal flap in repairing the urethral and penile defects not only reconstructs the structure of urethra and the shape of penis, but also restores the sensation and erectile function of penis, with few postoperative complications, no obvious scar hyperplasia, and high satisfaction degree of patients, which is worthy of clinical promotion.

     

  • 小儿烧伤发病率较高,烧伤患儿占同期烧伤患者总数的1/3~1/2,烧伤早期液体复苏不当可引起严重甚至不可逆的并发症1, 2。小儿全身血容量少,维持体液平衡能力差,烧伤后较成人更易发生休克,病死率更高。因此,早期行及时有效的液体复苏对烧伤患儿的预后具有重要意义。小儿生长发育阶段不同,器官及组织发育有差异,不同生长发育时期小儿生理需要量也不同,根据现有的小儿烧伤休克期液体公式补液,可能产生不良预后。本文通过回顾性分析南昌大学第一附属医院约6年间收治的重度及以上烧伤患儿休克期补液成分量、补液总量及临床疗效,评估烧伤患儿休克期液体复苏效果,分析失败原因,总结成功经验,以期对不同年龄不同严重程度烧伤重症患儿合理应用小儿液体复苏公式提供一定参考。

    本回顾性队列研究符合《赫尔辛基宣言》的基本原则。根据南昌大学第一附属医院伦理委员会政策,临床资料可以在不泄露患者身份的前提下进行分析、使用。

    纳入标准:年龄0~12岁,性别不限,烧伤总面积≥15%TBSA、深度为深Ⅱ度及以上的严重烧伤住院患儿3,伤后6 h内入院,住院时间>3 d,行休克期液体复苏治疗。排除标准:非热力因素造成的烧伤,入院前行除换药外的其他处理,合并吸入性损伤,合并皮肤撕脱伤、骨折、颅内出血、腹腔脏器出血等其他伤情,合并先天性疾病等其他基础疾病。

    2015年1月—2020年6月,南昌大学第一附属医院收治的235例严重烧伤患儿符合入选标准,纳入本研究。患儿中男150例、女85例,年龄3个月~12岁,入院时间为伤后30 min~5 h,烧伤总面积为15%~90%TBSA,133例合并1%~83%TBSAⅢ度烧伤,致伤原因中热液烫伤192例、火焰烧伤43例。入住烧伤ICU患儿51例,其中39例入院时即出现不同程度休克症状,13例因呼吸困难、面部水肿、特大面积烧伤等行气管切开及气管插管。

    患儿入院后立即行静脉输液抗休克治疗,根据烧伤深度采取不同的创面处理方法。计划按照国内小儿烧伤休克补液公式4计算补液量:(1)针对<3岁患儿,伤后第1个24 h补液总量=Ⅱ度与Ⅲ度烧伤面积之和(%TBSA)×体重(kg)×电解质和胶体2.00 mL·kg-1·%TBSA-1+水分100~150 mL·kg-1·d-1,其中电解质、胶体比例为1∶1。伤后第2个24 h电解质、胶体量减半(比例为1∶1),水分同伤后第1个24 h。(2)针对3~12岁患儿,伤后第1个24 h补液总量=Ⅱ度与Ⅲ度烧伤面积之和(%TBSA)×体重(kg)×电解质和胶体1.75 mL·kg-1·%TBSA-1+水分50~100 mL·kg-1·d-1,其中电解质、胶体比例为1∶1。伤后第2个24 h补液同<3岁患儿。电解质采用乳酸钠林格注射液(如有需要可加用碳酸氢钠溶液),胶体采用新鲜冰冻血浆、人血白蛋白,水分为50 g/L葡萄糖注射液。入院后即监测患儿心率、呼吸频率、血压、经皮动脉血氧饱和度(SpO2)等,利用输液泵监测输液进度并维持输液速度,根据患儿精神状态(意识清楚)、末梢循环(肤色正常、毛细血管充盈好、肢端温暖)、心率(140次/min以下)、血压[不低于80~90 mmHg(1 mmHg=0.133 kPa)]、脉压(不低于20 mmHg)、尿量(1.0~1.5 mL·kg-1·h-1)等适当调整补液量及速度。若烧伤后无明显胃肠道反应,可根据患儿营养情况、进食、消化能力及年龄等选择合适的食物尽早肠道喂养;若病情危重或进食效果不佳,可早期行肠内营养。早期预防性使用抗生素,并根据患儿血生化及血气分析结果及时纠正电解质、酸碱紊乱等。

    (1)统计所有患儿补液8 h与伤后第1、2个24 h实际输入和计划输入电解质量、胶体量、水分量、液体总量。(2)根据补液8 h尿量情况,将所有患儿分为尿量≥1 mL·kg-1·h-1的尿量维持满意组(119例)和尿量<1 mL·kg-1·h-1的尿量维持不满意组(116例)。2组患儿一般资料比较,差异无统计学意义(P>0.05),见表1。计算患儿补液8 h电解质系数、胶体系数、水分系数,其中电解质系数=实际输入电解质量÷(体重×Ⅱ度与Ⅲ度烧伤面积之和)、胶体系数=实际输入胶体量÷(体重×Ⅱ度与Ⅲ度烧伤面积之和)、水分系数=实际输入水分量÷(体重×Ⅱ度与Ⅲ度烧伤面积之和),计算方法下同。(3)根据烧伤总面积,将<3岁(155例)、3~12岁(80例)年龄段患儿均分为15%~25%TBSA组和>25%TBSA组。2个年龄段中不同面积组患儿一般资料比较,差异均无统计学意义(P>0.05),见表2。计算或统计患儿伤后第1、2个24 h电解质系数、胶体系数、水分系数、尿量;统计患儿伤后48 h体温、呼吸频率、心率、SpO2等无创监测指标以及血细胞比容、血小板计数、血红蛋白、白蛋白、肌酐、ALT等疗效指标(取血检测)水平。(4)统计所有患儿及<3岁、3~12岁年龄段患儿治疗期间并发症、治愈、好转出院、自动出院及死亡情况等预后及转归指标。

    表1  2组严重烧伤患儿一般资料比较
    组别例数性别(例)年龄[岁,MP25P75)]体重[kg,MP25P75)]伤后入院时间[h,MP25P75)]致伤原因(例)烧伤总面积[%TBSA,MP25P75)]Ⅲ度烧伤(例)
    热液烫伤火焰烧伤
    尿量维持满意组11971482.0(1.0,4.0)12(10,17)3(2,4)1001925(18,28)7346
    尿量维持不满意组11679371.0(1.0,2.8)12(10,15)3(2,4)922420(16,26)6056
    统计量值χ2=1.812Z=-1.938Z=-1.518Z=-1.049χ2=0.877Z=-1.753χ2=2.213
    P0.1780.0530.1290.2940.3490.0800.137
    注:TBSA为体表总面积
    下载: 导出CSV 
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    表2  2个年龄段中不同面积组间严重烧伤患儿一般资料比较
    年龄段与组别例数性别(例)年龄(岁,x¯±s体重(kg,x¯±s伤后入院时间(h,x¯±s致伤原因(例)Ⅲ度烧伤(例)
    热液烫伤火焰烧伤
    <3岁
    15%~25%TBSA组11279331.2±0.511.2±2.13.0±1.210665359
    >25%TBSA组4326171.2±0.610.9±3.22.7±1.33942716
    3~12岁
    15%~25%TBSA组5128235.1±2.620.1±8.72.7±1.331203021
    >25%TBSA组2917125.6±2.921.4±9.52.9±1.41613236
    统计量值1χ2=1.442t=0.342t=1.026t=1.270χ2=2.977
    P10.2300.7320.3050.2040.4660.084
    统计量值2χ2=0.104t=-0.606t=-0.876t=-0.815χ2=0.240χ2=3.470
    P20.7470.5450.3810.4150.6240.062
    注:TBSA为体表总面积;统计量值1P1值,统计量值2P2值分别为<3岁、3~12岁年龄段中2个面积组间各指标比较所得;“—”表示无此统计量值
    下载: 导出CSV 
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    采用SPSS 24.0统计软件进行分析,计量资料数据中符合正态分布者以x¯±s表示,行独立样本t检验或配对样本t检验;不符合正态分布者以MP25P75)表示,行Mann-Whitney U检验。计数资料以频数表示,行χ2检验或Fisher确切概率法检验(软件自动略去该统计量值)。P<0.05为差异有统计学意义。

    所有患儿补液8 h实际输入电解质量明显大于计划输入量,实际输入胶体量、水分量及液体总量均明显小于计划输入量(P<0.01);伤后第1、2个24 h实际输入电解质量明显大于计划输入量,实际输入水分量与液体总量明显小于计划输入量(P<0.01),实际输入胶体量与计划输入量相近(P>0.05)。见表3

    表3  235例严重烧伤患儿各时间段实际与计划补液情况比较[mL,M(P25P75)]
    补液情况与时间段电解质量胶体量水分量液体总量
    实际补液
    补液8 h350(250,500)100(0,200)150(100,250)600(480,850)
    伤后第1个24 h750(580,1 000)300(150,450)400(350,500)1 425(1 200,1 850)
    伤后第2个24 h480(350,650)150(50, 200)300(210,430)960(760,1 200)
    计划补液
    补液8 h132(100,187)132(100,187)500(450,600)792(678,936)
    伤后第1个24 h264(200,374)264(200,374)1 000(900,1 200)1 584(1 356,1 872)
    伤后第2个24 h132(100,187)132(100,187)1 000(900,1 200)1 280(1 150,1 560)
    Z113.0945.09613.2567.742
    P1<0.001<0.001<0.001<0.001
    Z213.2880.072-13.2523.867
    P2<0.0010.314<0.001<0.001
    Z313.1830.355-13.19110.091
    P3<0.0010.241<0.001<0.001
    注:Z1值、P1值,Z2值、P2值,Z3值、P3值分别为补液8 h、伤后第1个24 h、伤后第2个24 h实际补液与计划补液各指标比较所得
    下载: 导出CSV 
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    补液8 h,尿量维持满意组患儿电解质系数和胶体系数与尿量维持不满意组相近(P>0.05),尿量维持满意组患儿水分系数明显高于尿量维持不满意组(P<0.05)。见表4

    表4  2组严重烧伤患儿补液8 h补液系数比较
    表4.  [mL·kg-1·%TBSA-1,M(P25,P75)]
    组别例数电解质系数胶体系数水分系数
    尿量维持满意组1191.19(0.82,1.56)0.33(0,0.57)0.52(0.38,0.91)
    尿量维持不 满意组1161.25(0.83,1.66)0.33(0,0.58)0.42(0.31,0.71)
    Z-0.584-0.0222.574
    P0.5520.9830.010
    注:TBSA为体表总面积
    下载: 导出CSV 
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    <3岁患儿中,15%~25%TBSA组患儿伤后第1、2个24 h电解质系数、水分系数均明显高于>25%TBSA组,尿量明显低于>25%TBSA组(P<0.05或P<0.01),胶体系数与>25%TBSA组相近(P>0.05),见表5;15%~25%TBSA组患儿伤后48 h疗效指标中的血细胞比容、血小板计数、血红蛋白水平均明显高于>25%TBSA组,ALT水平则明显低于>25%TBSA组(P<0.05或P<0.01);2个面积组患儿伤后48 h其余疗效指标及无创监测指标水平比较,差异均无统计学意义(P>0.05),见表6

    表5  2个年龄段中不同面积组间严重烧伤患儿补液系数及尿量在伤后各时间段的比较[M(P25,P75)]
    年龄段与组别例数电解质系数(mL·kg-1·%TBSA-1胶体系数(mL·kg-1·%TBSA-1水分系数(mL·kg-1·%TBSA-1尿量(mL·kg-1·h-1
    第1个24 h第2个24 h第1个24 h第2个24 h第1个24 h第2个24 h第1个24 h第2个24 h
    <3岁
    15%~25%TBSA组1123.1(2.4,4.0)2.2(1.8,2.7)1.0(0.6,1.5)0.5(0.2,0.7)1.8(1.4,2.5)1.3(1.0,1.9)1.9(1.4,2.6)3.3(2.4,4.8)
    >25%TBSA组432.4(1.8,2.9)1.2(1.0,2,0)1.0(0.7,1.5)0.5(0.4,0.8)1.0(0.8,1.4)0.8(0.5,1.0)2.5(2.1,3.2)3.7(2.9,5.1)
    3~12岁
    15%~25%TBSA组512.1(1.7,3.1)1.3(0.9,1.9)0.7(0.3,1.1)0.3(<0.1,0.6)1.2(0.9,1.7)1.0(0.6,1.4)1.8(1.3,2.4)2.7(1.8,3.8)
    >25%TBSA组291.9(1.5,2.5)0.9(0.5,1.4)1.0(0.6,1.1)0.5(0.3,0.7)0.8(0.5,0.9)0.5(0.4,0.9)1.7(1.2,2.2)2.9(2.3,3.5)
    Z1-3.867-5.396-0.298-1.799-6.993-5.062-3.4171.503
    P1<0.001<0.0010.7660.072<0.001<0.001<0.0010.044
    Z2-2.042-2.297-1.608-2.480-4.884-3.4480.555-0.861
    P20.0410.0220.1080.013<0.0010.0010.5790.389
    注:TBSA为体表总面积;Z 1值、P1值,Z2值、P2值分别为<3岁、3~12岁年龄段中不同面积组间各指标比较所得
    下载: 导出CSV 
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    表6  2个年龄段中不同面积组间严重烧伤患儿伤后48 h无创监测指标及疗效指标水平比较
    年龄段与组别例数体温(℃,x¯±s心率(次/min,x¯±s呼吸频率(次/min,x¯±sSpO2MP25P75)]血细胞比容[MP25P75)]血小板计数[×109/L, MP25P75)]血红蛋白[g/L, MP25P75)]白蛋白[g/L, MP25P75)]肌酐[μmoI/L, MP25P75)]ALT[U/L, MP25P75)]
    <3岁
    15%~25%TBSA组11236.8±0.4131±1230±41(1,1)0.32(0.29,0.35)268(229,332)103(95,111)31(28,33)22(18,24)25(22,30)
    >25%TBSA组4336.7±0.3133±1330±41(1,1)0.30(0.28,0.32)235(195,274)97(93,108)33(28,34)20(18,23)31(22,42)
    3~12岁
    15%~25%TBSA组5136.8±0.3132±1028±51(1,1)0.35±0.05259±74113(105,122)30±431(24,37)22(17,25)
    >25%TBSA组2936.7±0.4127±1427±41(1,1)0.34±0.06231±82109(97,118)29±629(25,34)23(19,37)
    统计量值1t=-0.820t=-0.968t=-1.112Z=-0.695Z=-2.720Z=-3.099Z=-2.063Z=1.885Z=-1.153Z=-2.481
    P10.4120.3340.2660.4870.0070.0020.0390.0590.2490.013
    统计量值2t=0.035t=1.847t=1.301Z=-0.407t=1.041t=1.585Z=-1.522t=1.287Z=-0.480Z=-1.463
    P20.9720.0690.1970.6840.3010.1170.1280.2020.6310.143
    注:TBSA为体表总面积,SpO2为经皮动脉血氧饱和度,ALT为丙氨酸转氨酶;统计量值1P1值,统计量值2P2值分别为<3岁、3~12岁年龄段中不同面积组间各指标比较所得
    下载: 导出CSV 
    | 显示表格

    3~12岁患儿中,15%~25%TBSA组患儿伤后第1、2个24 h电解质系数、水分系数均明显高于>25%TBSA组,伤后第2个24 h胶体系数明显低于>25%TBSA组(P<0.05或P<0.01),伤后第1个24 h胶体系数和伤后第1、2个24 h尿量与>25%TBSA组相近(P>0.05),见表5;2个面积组患儿伤后48 h无创监测指标及疗效指标水平比较,差异均无统计学意义(P>0.05),见表6

    治疗期间共17例患儿发生并发症。235例患儿中,治愈211例,占89.79%;好转出院5例,占2.13%;自动出院16例,占6.81%;死亡3例,占1.28%。<3岁患儿中,发生全身感染6例、胃肠道紊乱4例,治愈138例,好转出院2例,自动出院13例,死亡2例;3~12岁患儿中,发生全身感染4例、胃肠道紊乱1例、应激性溃疡1例、肺水肿1例,治愈73例,好转出院3例,自动出院3例,死亡1例。

    烧伤是我国乃至全世界致伤、致残的主要原因之一,也是儿童伤害和意外死亡的主要因素。伤后48 h是小儿烧伤治疗的关键时期,液体复苏时应在诊断休克后尽早开放2条静脉通路5。小儿烧伤的液体复苏遵循与成人烧伤复苏相同的原则:足够的容量恢复和纠正电解质紊乱,同时防止肾功能衰竭(复苏不足)和肺水肿(过度复苏)。烧伤早期及时的液体复苏可改善组织灌注不足,减少早期创面加深问题6

    本研究中所有患儿补液8 h及伤后第1、2个24 h实际输入电解质量明显高于计划输入量,水分量及液体总量明显低于计划输入量,这与苏海涛等7根据临床工作进行分析得出休克期补液适当增加电解质比例、减少水分,可获得更好的临床疗效的结果相一致。由于国内小儿烧伤休克补液公式采用生理盐水作为电解质溶液,而本研究采用的是钠离子浓度相对较低的乳酸钠林格注射液,为了满足电解质需要量,在输入电解质溶液时相对补充了更多的水分。因此补液8 h内实际输入电解质量较计划量多,水分量较计划量少。本研究显示,由于临床上客观条件限制,往往入院后不能及时输入胶体溶液,需输入电解质溶液快速扩容,导致8 h实际输入电解质溶液增多、胶体减少。烧伤早期钠离子渗出,电解质渗透压降低,而水分可随之同步丢失。适量增加电解质可维持电解质渗透压以及减缓水分的丢失,起到扩张血浆容量的作用,但复苏时电解质使用过量可造成液体超负荷,造成“液体蠕变”8。“液体蠕变”可致腹腔间室综合征、呼吸和心力衰竭等并发症9。小儿烧伤后对体液丧失的耐受性差,根据参考公式可能会输入过量葡萄糖,易发生低渗性脱水、低钠血症、尿糖等10。尿量是烧伤休克液体复苏最常用的调整补液量的重要指标,将其与微循环、细胞代谢和血流动力学指标结合行综合分析,可有效提高休克期复苏效果11。小儿复苏期间维持尿量应不少于1 mL·kg-1·h-1。本研究中患儿补液8 h仅有119例(50.64%)尿量维持满意,补液8 h尿量维持不满意患儿与尿量维持满意患儿比较,水分补充较少,说明应在补液早期适量增加水分输入。本研究显示,虽然所有患儿补液8 h及伤后第1、2个24 h实际输入水分量均显著小于计划输入量,但可通过早期喂养或早期肠内营养等补充相对不足的水分。因此,根据临床监护指标合理调整液体配比及使用量,且多种类型溶液交替使用,既可改善循环,又可避免补液过多导致不可逆损伤,以达到较佳的治疗效果。

    本研究根据液体复苏公式,将患儿分为<3岁、3~12岁2个年龄段。<3岁患儿中,15%~25%TBSA组患儿伤后第1、2个24 h电解质系数、水分系数高于>25%TBSA组,而尿量低于>25%TBSA组(可能与>25%TBSA组使用利尿剂有关),且通过比较2个面积组无创监测指标及疗效指标,说明>25%TBSA组复苏稍有不足,应适量增加补液量,以达到复苏满意。3~12岁患儿中,15%~25%TBSA组患儿伤后第1、2个24 h电解质系数、水分系数明显高于>25%TBSA组,伤后第2个24 h胶体系数明显低于>25%TBSA组,2个面积组患儿伤后第1个24 h胶体系数和伤后第1、2个24 h尿量及伤后48 h无创监测指标及疗效指标无明显差异,表明特重度烧伤患儿现有的低电解质量、低水分量、高胶体量的补液方法比较恰当,复苏效果较佳,值得临床借鉴。

    正确评估和判断烧伤休克期液体复苏效果需要及时有效的监测手段。烧伤休克液体复苏的最终指标为与氧代谢有关的指标。余惠等12研究表明,在烧伤休克期应用脉搏轮廓心输出量(PiCCO)监测结合常规监测指标,可减少烧伤休克期胶体的使用,改善组织灌注效果更优,复苏效果更佳。但PiCCO为侵入性监测,小儿免疫系统发育不完全,应用PiCCO监测可能会增加导管型感染的风险,且增加护理难度。有学者对侵入性监测行荟萃分析,结果显示,虽然患者心脏指数和尿量显著改善13,但尚无足够的证据来确定侵入性监测指导液体复苏是否能改善严重烧伤后的患者预后,需要进一步研究。休克期无创监测的基本指标包括意识、血压、心率、尿量和末梢血氧饱和度。Tapking等14强调了非侵入性监测对烧伤休克治疗的指导意义。本研究也主要采用无创监测,且有51例患儿入住烧伤ICU。在烧伤ICU中可更好地实时监控患儿生命体征及输液情况等,以随时调整液体复苏方案。235例患儿中治愈患儿占89.79%,死亡3例,死亡时均度过休克期;共17例患儿发生并发症,与休克期液体复苏无明显关系。全部患儿伤后48 h复苏指标等均反映复苏满意,表明无创监测适合严重烧伤患儿休克期液体复苏。今后对那些特别危重的烧伤患儿,可以尝试应用PiCCO监测,对比其与无创指标的监测效果,寻找更适合严重烧伤患儿休克期监测的方法及指标。

    综上,严重烧伤小儿早期液体复苏电解质量超出公式计算量,原因与早期血浆量不足,需电解质溶液快速扩容有关;且由于乳酸钠林格注射液钠离子浓度低,液体复苏时可适当减少水分输入。<3岁患儿中,特重度烧伤患儿较重度烧伤患儿在液体复苏时应适量增加补液量;3~12岁患儿中,特重度烧伤患儿较重度烧伤患儿在液体复苏时应适当增加胶体量;无创监测指标可用于监控严重烧伤患儿血流动力学和指导其液体复苏,但仍需进一步研究。未来本研究团队将进一步讨论有效的小儿烧伤休克期液体复苏方案及复苏目标的设定,以使患儿能平稳度过休克期,改善预后。

    ·科技快讯·

    高蛋白摄入改善烧伤患者临床预后和营养状况的系统评价

    严重烧伤可导致患者产生局部和全身反应,使机体处于高代谢状态。目前的指南建议摄入高蛋白以缓解烧伤的分解代谢反应,但仅基于少量临床试验证据。本文通过在8个数据库中收集纳入接受2种或2种以上蛋白质摄入,摄入水平等于或高于健康个体推荐水平(0.75 g·kg-1·d-1)的烧伤患者的临床试验,并提供下列至少1项预定结果:氮平衡、住院时间、体重变化、存活率、物理治疗指数、蛋白质合成率、免疫学测量值、菌血症天数、全身应用抗生素天数和净蛋白质合成,来系统评价高蛋白摄入对烧伤患者临床预后和营养状况的改善作用。最终共纳入6项研究,其中4项为随机对照试验。结果显示没有可靠的证据表明高蛋白饮食能改善氮平衡,但部分证据表明高蛋白饮食能使患者体重增加。其中一项小型研究报告称,儿童存活率提高,感染率和一些免疫功能指标明显改善,但住院时间没有明显缩短。少量证据表明肌肉力量和耐力有所改善,但肌肉或皮肤中的蛋白质合成或全身净蛋白质合成没有明显增加。因此,目前只有极少量的证据证实烧伤患者接受高蛋白饮食具有合理性。

    翁婷婷,编译自《Burns》,2021,5:S0305-4179(21)00069-3;韩春茂,审校

    严重烧伤会导致未成熟的中性粒细胞增多且促进其向释放细胞因子的T细胞亚型转变

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