摘要
目的采用动脉波经肺稀释法验证严重烧伤患者液体复苏后心肌存在收缩力降低改变。方法选择上海交通大学医学院附属瑞金医院急诊科2011年10月至2012年7月收治入院的7例热液灼伤患者,患者均在伤后3h内入院,烧伤总面积均≥70%体表总面积(TBSA),Ⅲ度烧伤面积≥30%TBSA。入院后以1.5mL·kg-1·%TBSA-1作为预判公式,然后根据患者情况调整液体复苏方案,观察尿量指标临床评价平稳度过休克期。应用动脉波经肺稀释方法(PiCCO系统)监测患者烧伤休克期血液动力学动态变化,以平均动脉压、中心静脉压、心指数、全心射血分数、肺间质水量评估液体复苏时心肌收缩力、心脏泵功能、血管张力和间质液体分布情况。结果烧伤后早期心输出量及心指数即出现下降明显,未进行液体复苏前(0时相)仅为(3.53±0.38)L/min和(2.07±0.28)L·min-1·m-2,为正常人的68%,经液体复苏后在伤后16h内持续降低,但尿量可维持于30～60mL/h;烧伤后心肌收缩力显著下降[伤后入院时患者左心室收缩力指数(980±234.9),较正常值减少约18.3%]并维持于低水平直至伤后48h后开始上升。烧伤后早期入院时未进行液体复苏时,肺血管外肺水量(6.0±0.42)mL/kg已呈现增加的趋势,接近正常值上限;随着液体复苏的进行其血管外肺水量显著增多,到伤后48h达到高峰(14.0±0.83)mL/kg;而直到伤后72h,在没有外界干预情况下逐渐减少。结论烧伤早期容量复苏阶段存在心肌收缩力降低,需要在烧伤早期液体复苏同时,在心肌收缩力维护和血管张力调节、减少肺间质水肿环节优化液体复苏质量。
Objective To verify the early myocardial contractility impairment coincident with effective fluid resuscitation for extensive burn patients by using continuous PiCCO measurement （ Pulsion Medical Systems, Munich, Germany）. Methods Extensive burn patients with more than 70% TBSA （total burn surface area） and Ⅲ degree no less than 30% with in 3 hours who was simply suffering from scalding were enrolled into the study. Fluid resuscitation were immediately administered according to the protocol of 1.5 mL· kg^-1·% TBSA^-1 and revised by patients＇ clinical manifestation. Hemodynamic criteria, such asmean blood pressure （MBP） , central venous pressure （ CVP）, cardiac index （CI） , general ejective fraction （GEF） and extravascular lung water（ EVLW）, were collected although hypovolemic phase with effective fluid resuscitation to evaluate patients＇ cardiac contractility, cardiac pump function, resistance of blood vessels and pulmonary interstitial edema. Results Under the resuscitation protocol, it was effective to maintain urine output of 30 - 60 mL/h indicating effective fluid resuscitation without prescription of sedative medications and angio-active agents. CO and CI were significantly decreased to （ 3.53 ±0.38 ） L/min and （2.07±0.28） L ·min^-1·m^-2, only 68% of the normal value, respectively at early stage postburn and persisted at the low level until 16 hours postburn. This was characterized by the significant cardiac contractility impairment, indicated by left ventricular contract index （dPmax） at the value of 980 ± 234.9, only 18.3% that of the normal value. It persisted until 48 hours postburn while EVLWI reached its peak at （ ld. 0 ±0.83 ） mL/kg. Furthermore, the extravascular lung water was impend to reach a high level of （6.0±0.42） mL/kg soon after the burn even before fluid therapy and it started to slope down after 72 hours postburn spontaneously. Conclusions There existed the early myocardial contractility impairment soon after the extensive burns coincident with effective fluid resuscitation among the extensive burn patients. And this could be a clue for us to pursue preservation of myocardial contractility to restore pump function, minimize pulmonary edema so as to preserve effective tissue perfusion.
出处
《中华损伤与修复杂志（电子版）》
CAS
2012年第5期30-33,共4页
Chinese Journal of Injury Repair and Wound Healing(Electronic Edition)
基金
上海市卫生局科研基金(2009052)
关键词
烧伤
补液疗法
心肌收缩
Burns
Fluid therapy
Myocardial contraction
