EVLWI和ITBVI在创伤性休克合并肺挫伤患者液体管理中的价值研究
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摘要
目的:探讨血管外肺水指数(extravascular lung water index,EVLWI)和胸腔内血容量指数(intrathoracic blood volume index,ITBVI)在创伤性休克合并肺挫伤患者液体管理中的价值。方法:选择2016-01—2017-12期间在我院重症医学科救治的60例创伤性休克合并肺挫伤的患者作为研究对象,并采用随机数字表的方法将其分为试验组及对照组,各30例。试验组采用EVLWI与ITBVI指导液体复苏,对照组采用中心静脉压(central venous pressure,CVP)指导液体复苏。记录两组患者液体复苏前、24h、72h时APACHEⅡ评分、平均动脉压(MAP)、去甲肾上腺素用量、血清乳酸水平(Lac)、氧合指数。记录机械通气时间、ICU入住时间、及28d ARDS、MODS发生率及病死率。结果:两组患者在复苏后,MAP及氧合指数均较液体复苏前升高,Lac均较前液体复苏前下降,差异均有统计学意义(P<0.05)。液体复苏后,MAP在两组间差异无统计学意义(P>0.05)。试验组Lac浓度较对照组下降更加明显,而氧合指数显著高于对照组,差异均有统计学意义(P<0.05)。试验组复苏液体总量及去甲肾上腺素用量均显著低于对照组,差异有统计学意义(P<0.05)。试验组机械通气时间、ICU入住时间、ARDS发生率、MODS发生率及28d死亡率均显著低于对照组,差异有统计学意义(P<0.05)。结论:EVLWI和ITBVI指导创伤性休克合并肺挫伤患者进行液体管理,可有效减少液体入量,缩短机械通气时间,降低ARDS、MODS发生率及28d病死率。
Objective:To explore the value of extravascular lung water index and intrathoracic blood volume index in fluid management of patients with traumatic shock combined with pulmonary contusion.Method:Sixty cases of traumatic shock combined with pulmonary contusion were collected in our hospital from January 2016 to December 2017,and the randomized digital table was used to divide them into experimental and control groups(n=30,Respectively).In the experimental group,the fluid resuscitation was guided by the extravascular lung water index(EVLWI)and the blood volume index(intrathoracic blood volume index,ITBVI)in the thoracic cavity.The control group was guided by central venous pressure(CVP).The scores of APACHE II,mean arterial pressure(MAP),norepinephrine,serum lactate level and oxygenation index were recorded in two groups of patients before and 24 hand 72 hafter resuscitation.The mechanical ventilation time,ICU check-in time,and 28 dARDS,MODS incidence and mortality were recorded.Result:After the resuscitation,the MAP and the oxygenation index of the two groups were higher than that before the fluid resuscitation,and the Lac decreased compared with the pre fluid resuscitation(P<0.05).After fluid resuscitation,there was no significant difference in MAP between the two groups(P>0.05).The concentration of Lac in the experimental group decreased more significantly than that in the control group,while the oxygenation index was significantly higher than that in the control group,and the difference was statistically significant(P<0.05).The total amount of fluid resuscitation and the dosage of norepinephrine in the experimental group were significantly lower than those in the control group(P<0.05).The time of mechanical ventilation,the ICU time,the incidence of ARDS,the incidence of MODS and the mortality of 28 din the experimental group were significantly lower than those in the control group,and the difference was statistically significant(P<0.05).Conclusion:EVLWI and ITBVI can guide the fluid management in patients with traumatic shock and pulmonary contusion,which can effectively reduce the volume of liquid,shorten the time of mechanical ventilation,reduce the incidence of ARDS and MODS and the mortality of 28 d.
Objective:To explore the value of extravascular lung water index and intrathoracic blood volume index in fluid management of patients with traumatic shock combined with pulmonary contusion.Method:Sixty cases of traumatic shock combined with pulmonary contusion were collected in our hospital from January 2016 to December 2017,and the randomized digital table was used to divide them into experimental and control groups(n=30,Respectively).In the experimental group,the fluid resuscitation was guided by the extravascular lung water index(EVLWI)and the blood volume index(intrathoracic blood volume index,ITBVI)in the thoracic cavity.The control group was guided by central venous pressure(CVP).The scores of APACHE II,mean arterial pressure(MAP),norepinephrine,serum lactate level and oxygenation index were recorded in two groups of patients before and 24 hand 72 hafter resuscitation.The mechanical ventilation time,ICU check-in time,and 28 dARDS,MODS incidence and mortality were recorded.Result:After the resuscitation,the MAP and the oxygenation index of the two groups were higher than that before the fluid resuscitation,and the Lac decreased compared with the pre fluid resuscitation(P<0.05).After fluid resuscitation,there was no significant difference in MAP between the two groups(P>0.05).The concentration of Lac in the experimental group decreased more significantly than that in the control group,while the oxygenation index was significantly higher than that in the control group,and the difference was statistically significant(P<0.05).The total amount of fluid resuscitation and the dosage of norepinephrine in the experimental group were significantly lower than those in the control group(P<0.05).The time of mechanical ventilation,the ICU time,the incidence of ARDS,the incidence of MODS and the mortality of 28 din the experimental group were significantly lower than those in the control group,and the difference was statistically significant(P<0.05).Conclusion:EVLWI and ITBVI can guide the fluid management in patients with traumatic shock and pulmonary contusion,which can effectively reduce the volume of liquid,shorten the time of mechanical ventilation,reduce the incidence of ARDS and MODS and the mortality of 28 d.
引文
[1] Ryan KL,Walter B.Cannon's World War I experience:treatment of traumatic shock then and now[J].Adv Physiol Educ,2018,42(2):267-276.
[2] Delano MJ,Rizoli SB,Rhind SG,et al.Prehospital Resuscitation of Traumatic Hemorrhagic Shock with Hypertonic Solutions Worsens Hypocoagulation and Hyperfibrinolysis[J].Shock,2015,44(1):25-31.
[3]Mahmood I,El-Menyar A,Younis B,et al.Clinical Significance and Prognostic Implications of Quantifying Pulmonary Contusion Volume in Patients with Blunt Chest Trauma[J].Med Sci Monit,2017,23(1):3641-3648.
[4]胡雪珍,龚裕强,杨鹏,等.血管外肺水指数和肺血管通透性指数评估重症患者急性呼吸窘迫综合征程度的可靠性[J].中华麻醉学杂志,2016,36(1):88-891.
[5]中国医师协会急诊分会.创伤失血性休克诊治中国急诊专家共识[J].中华急诊医学杂志,2017,26(12):1029-1038.
[6] Rossaint R,Bouillon B,Cerny V,et al.The European guideline on management of major bleeding and coagulopathy following trauma:fourth edition[J].Crit Care,2016,20(1):100.
[7] Kheirabadi BS,Miranda N,Terrazas IB,et al.Does small-volume resuscitation with crystalloids or colloids influence hemostasis and survival of rabbits subjected to lethal uncontrolled hemorrhage?[J].J Trauma Acute Care Surg,2017,82(1):156-164.
[8] Butler FK Jr.Fluid Resuscitation in Tactical Combat Casualty Care:Yesterday and Today[J].Wilderness Environ Med,2017,28(2S):S74-S81.
[9]陈孝平,汪建平.外科学[M].北京:人民卫生出版社,2013:267.
[10]殷娟,张明红.肺挫伤患者早期外周血细胞因子水平的改变及临床意义[J].中国实验诊断学,2017,21(3):435-437.
[11]Daurat A,Millet I,Roustan JP,et al.Thoracic Trauma Severity score on admission allows to determine the risk of delayed ARDS in trauma patients with pulmonary contusion[J].Injury,2016,47(1):147-153.
[12]Brown LM,Matthay MA.Measuring the quantity of pulmonary edema in clinical lung injury[J].Crit Care Med,2010,38(1):312-324.
[13]Jozwiak M,Teboul JL,Monnet X.Extravascular lung water in critical care:recent advances and clinical applications[J].Ann Intensive Care,2015,5(1):38.
[14]夏炳杰,施善阳.脉搏指示连续心排血量监测技术在感染性休克并急性呼吸窘迫综合征患者液体管理中的应用效果[J].实用心脑肺血管病杂志,2016,24(5):100-102.
[15]张建,乔鲁军,崔文娟,等.血管外肺水指数对脓毒症相关急性呼吸窘迫综合征预后的预测价值[J].重庆医学,2017,46(21):2988-2991.
[16]张伟强,李玉著,王晓芝,等.USCOM对肺挫伤致ARDS患者液体管理的指导作用[J].滨州医学院学报,2014,37(4):251-254.
[2] Delano MJ,Rizoli SB,Rhind SG,et al.Prehospital Resuscitation of Traumatic Hemorrhagic Shock with Hypertonic Solutions Worsens Hypocoagulation and Hyperfibrinolysis[J].Shock,2015,44(1):25-31.
[3]Mahmood I,El-Menyar A,Younis B,et al.Clinical Significance and Prognostic Implications of Quantifying Pulmonary Contusion Volume in Patients with Blunt Chest Trauma[J].Med Sci Monit,2017,23(1):3641-3648.
[4]胡雪珍,龚裕强,杨鹏,等.血管外肺水指数和肺血管通透性指数评估重症患者急性呼吸窘迫综合征程度的可靠性[J].中华麻醉学杂志,2016,36(1):88-891.
[5]中国医师协会急诊分会.创伤失血性休克诊治中国急诊专家共识[J].中华急诊医学杂志,2017,26(12):1029-1038.
[6] Rossaint R,Bouillon B,Cerny V,et al.The European guideline on management of major bleeding and coagulopathy following trauma:fourth edition[J].Crit Care,2016,20(1):100.
[7] Kheirabadi BS,Miranda N,Terrazas IB,et al.Does small-volume resuscitation with crystalloids or colloids influence hemostasis and survival of rabbits subjected to lethal uncontrolled hemorrhage?[J].J Trauma Acute Care Surg,2017,82(1):156-164.
[8] Butler FK Jr.Fluid Resuscitation in Tactical Combat Casualty Care:Yesterday and Today[J].Wilderness Environ Med,2017,28(2S):S74-S81.
[9]陈孝平,汪建平.外科学[M].北京:人民卫生出版社,2013:267.
[10]殷娟,张明红.肺挫伤患者早期外周血细胞因子水平的改变及临床意义[J].中国实验诊断学,2017,21(3):435-437.
[11]Daurat A,Millet I,Roustan JP,et al.Thoracic Trauma Severity score on admission allows to determine the risk of delayed ARDS in trauma patients with pulmonary contusion[J].Injury,2016,47(1):147-153.
[12]Brown LM,Matthay MA.Measuring the quantity of pulmonary edema in clinical lung injury[J].Crit Care Med,2010,38(1):312-324.
[13]Jozwiak M,Teboul JL,Monnet X.Extravascular lung water in critical care:recent advances and clinical applications[J].Ann Intensive Care,2015,5(1):38.
[14]夏炳杰,施善阳.脉搏指示连续心排血量监测技术在感染性休克并急性呼吸窘迫综合征患者液体管理中的应用效果[J].实用心脑肺血管病杂志,2016,24(5):100-102.
[15]张建,乔鲁军,崔文娟,等.血管外肺水指数对脓毒症相关急性呼吸窘迫综合征预后的预测价值[J].重庆医学,2017,46(21):2988-2991.
[16]张伟强,李玉著,王晓芝,等.USCOM对肺挫伤致ARDS患者液体管理的指导作用[J].滨州医学院学报,2014,37(4):251-254.