小儿大面积烧伤应用悬浮床时机探讨
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摘要
目的探讨应用悬浮床治疗小儿大面积烧伤的合理时机。方法对2000年1月至2017年12月解放军联勤保障部队第九九〇(原一五九)医院全军烧伤中心收治的符合入选标准的107例大面积烧伤患儿的临床资料进行回顾性分析。根据应用悬浮床的时机不同分为2组,伤后3 d以内应用悬浮床的为对照组(n=49),伤后第4天至第6天应用悬浮床的为试验组(n=58),比较2组休克期补液总量及胶体、晶体和水分各成份补液量、尿量、休克期复苏指标及伤后内脏并发症、高钠血症的发生率和病死率,比较创面成痂、脱痂及愈合时间、创面细菌培养阳性率和脓毒症发生率,并对2组的悬浮床床沙板结时间和床沙细菌培养阳性率进行比较。对数据行t检验和χ2检验。结果试验组患儿伤后第1个24 h晶体、胶体、水分补液量、补液总量分别为(0. 97±0. 10) mL·kg~(-1)·%TBSA-1、(0. 67±0. 13) mL·kg~(-1)·%TBSA-1、(1 233.00±254. 00) m L、(2 265. 00±958. 00) m L,对照组患儿伤后第1个24 h晶体、胶体、水分补液量、补液总量分别为(1. 18±0. 13) mL·kg~(-1)·%TBSA-1、(0. 97±0. 10) mL·kg~(-1)·%TBSA-1、(1 635.00±283.00) m L、(2 979.00±973.00) m L,2组比较差异均有统计学意义(t=9. 585、13. 617、7. 736、3. 811,P值均小于0. 01);试验组患儿伤后第2个24 h晶体、胶体、水分补液量、补液总量分别为(0. 53±0. 07) mL·kg~(-1)·%TBSA-1、(0. 49±0.06) mL·kg~(-1)·%TBSA-1、(1 110. 00±229. 00) m L、(1 755. 00±649. 00) m L,对照组患儿伤后第2个24 h晶体、胶体、水分补液量、补液总量分别为(0. 74±0. 10) mL·kg~(-1)·%TBSA-1、(0. 75±0.12) mL·kg~(-1)·%TBSA-1、(1 542. 00±288. 00) m L、(2 479. 00±771. 00) m L,试验组较对照组患儿补液量均显著减少,差异均有统计学意义(t=12. 529、13. 653、9. 635、5. 279,P值均小于0. 01); 2组休克期各项复苏指标除尿量无明显差别外,试验组心率(115. 00±5. 00)次/min、平均动脉压(MAP)(53. 00±2. 70) mm Hg、中心静脉压(CVP)(8. 00±0. 80) cm H2O、血乳酸(2. 00±0. 60) mmol/L、剩余碱(-2. 10±0. 70) mmol/L、红细胞比容(HT)(0. 42±0. 02)、血白蛋白(35. 00±1. 40) g/L,与对照组心率(126. 00±5. 00)次/min、MAP(56. 00±3. 30) mm Hg、CVP(9. 80±1. 50) cm H2O、血乳酸(3. 80±0. 60) mmol/L、剩余碱(-4. 40±0. 60) mmol/L、HT(0. 53±0. 03)、血白蛋白(33. 00±2. 10) g/L比较,差异均有统计学意义(t=10. 234、5. 585、8. 214、16. 117、-17. 451、20. 448、-3. 989,P值均小于0. 01);试验组患儿高钠血症、内脏并发症发生率分别为3. 4%、10. 3%,较对照组(18. 4%、26. 5%)均显著降低,差异有统计学意义(χ2=6. 410、4. 765,P值均小于0. 05);病死率对照组为4. 1%,试验组为1. 7%,差异无统计学意义(P> 0. 05)。创面细菌培养阳性率和脓毒症发生率,2组比较差异均无统计学意义(P值均大于0. 05)。创面成痂时间对照组较试验组提前,差异有统计学意义(t=-5. 579,P <0. 01),试验组较对照组创面脱痂、愈合时间明显提前,差异均有统计学意义(t=6. 760、4. 212,P值均小于0. 01);悬浮床床沙板结时间和床沙细菌培养阳性率比较,对照组的床沙板结时间明显早于试验组,差异有统计学意义(t=-15. 010,P <0. 01);床沙细菌培养阳性率高于试验组,差异有统计学意义(χ2= 4.356,P< 0.05)。结论大面积烧伤患儿首次应用悬浮床的时机应选择在伤后第4天至第6天,既有利于休克期的平稳度过,降低病死率,减少创面损伤及并发症发生,促进创面愈合,同时又能增加悬浮床的使用寿命和使用率。床沙细菌培养阳性率高于试验组,差异有统计学意义(χ2=4. 356,P <0. 05)。结论大面积烧伤患儿首次应用悬浮床的时机应选择在伤后第4天至第6天,既有利于休克期的平稳度过,降低病死率,减少创面损伤及并发症发生,促进创面愈合,同时又能增加悬浮床的使用寿命和使用率。
Objective To explore the appropriate time for the application of suspended bed in the treatment of severely burned children. Methods A retrospective analysis was performed based on the clinical data of 107 cases of severely burned children who were admitted to the Military Burn Center of the990 th( formerly 159 th) Hospital of Joint Service Support Force of People' s Liberation Army from January2000 to December 2017. Cases were divided into two groups according to the time of the application of suspended bed. In control group( n = 49),patients started to use suspended bed within 3 days after injury,while suspended beds were put into use from 4 to 6 days after injury in experimental group( n = 58). The following indicators were collected and analyzed: total amount of fluid infusion,amount of colloid liquid,crystal liquid and water,urine volume,resuscitation index in shock stage,visceral complications after injury,hypernatremia,mortality; time of scab formation,time of scab removal,time of wound healing,positive rate of bacterial culture and the incidence of sepsis; time of sand bonding in suspended bed and positive rate of bacterial culture of bed sediment. Date were compared with t test and χ2 test. Results In experimental group,the amount of crystal liquid,colloid liquid,water and total amount of fluid infusion in first 24 hours were( 0. 97 ± 0. 10) m L · kg-1·% TBSA-1,( 0. 67 ± 0. 13) mL·kg~(-1)·% TBSA-1,( 1 233. 00 ± 254. 00) m L,( 2 265. 00 ± 958. 00) m L,and these indicators in first 24 hours in control group were( 1. 18 ± 0. 13) m L · kg-1·% TBSA-1,( 0. 97 ± 0. 10) mL·kg~(-1)·% TBSA-1,( 1 635. 00 ±283. 00) m L,( 2 979. 00 ± 973. 00) m L,the difference between the two groups was statistically significant( t = 9. 585,13. 617,7. 736,3. 811,with P values below 0. 01). The amount of crystal liquid,colloid liquid,water and total amount of fluid infusion in the second 24 hours in experimental group were( 0. 53 ±0. 07) m L· kg-1·% TBSA-1,( 0. 49 ± 0. 06) mL·kg~(-1)·% TBSA-1,( 1 110. 00 ± 229. 00) m L,( 1 755. 00 ± 649. 00) m L; in control group, these indicators in the second 24 hours were( 0. 74 ± 0. 10) mL·kg~(-1)·% TBSA-1,( 0. 75 ± 0. 12) mL·kg~(-1)·% TBSA-1,( 1 542. 00 ±288. 00) m L,( 2 479. 00 ± 771. 00) m L. The amount of fluid in experimental group was significantly lower than that in control group,the difference was statistically significant( t = 12. 529,13. 653,9. 635,5. 279,with P values below 0. 01). The indexes of resuscitation in experimental group were listed following: heart rate( 115. 00 ± 5. 00) beats/min,mean arterial pressure( MAP)( 53. 00 ± 2. 70) mm Hg,central venous pressure( CVP)( 8. 00 ± 0. 80) cm H2 O,lactic acid( 2. 00 ± 0. 60) mmol/L,residual base(-2. 10 ±0. 70) mmol/L,hematocrit( HT)( 0. 42 ± 0. 02) and albumin( 35. 00 ± 1. 40) g/L. The indexes of resuscitation in control group were listed following: heart rate( 126. 00 ± 5. 00) beats/min,MAP( 56. 00 ±3. 30) mm Hg, CVP( 9. 80 ± 1. 50) cm H2 O, lactic acid( 3. 80 ± 0. 60) mmol/L, residual base(-4. 40 ± 0. 60) mmol/L,HT( 0. 53 ± 0. 03) and albumin( 33. 00 ± 2. 10) g/L. These indicators in experimental group were better than those in control group except urine volume, the difference was statistically significant( t = 10. 234,5. 585,8. 214,16. 117,-17. 451,20. 448,-3. 989,with P values below 0. 01). The incidence of hypernatremia and visceral complications in experimental group were 3. 4%and 10. 3% respectively,which were significantly lower than those in control group( 18. 4% and 26. 5%)( χ2= 6. 410,4. 765,with P values below 0. 05),mortality in control group was 4. 1% and 1. 7% in experimental group,there was no significant difference( P > 0. 05). There was no significant difference in the positive rate of bacterial culture and the incidence of sepsis between the two groups( with P values above0. 05). Scab formation in control group was earlier than experimental group,the difference was statistically significant( t =-5. 579,P < 0. 01),however,the time of scab removal and wound healing in experimental group was obviously earlier than control group,the difference was statistically significant( t =-6. 760,4. 212,with P values below 0. 01). In control group,the time of sand bonding was significantly earlier than experimental group,the difference was statistically significant( t =-15. 010,P < 0. 05),and the positive rate of bacterial culture of bed sediment was higher than experimental group,the difference was statistically significant( χ2=4. 356,P < 0. 05). Conclusions The appropriate time for the first application of suspended bed in the treatment of severely burned children should be from 4 to 6 days after injury,which can help the patients get through the shock period successfully and promote wound healing with lower mortality,wound injury and complications.Meanwhile,this timing also can increase the service life and utilization rate of suspended bed.
Objective To explore the appropriate time for the application of suspended bed in the treatment of severely burned children. Methods A retrospective analysis was performed based on the clinical data of 107 cases of severely burned children who were admitted to the Military Burn Center of the990 th( formerly 159 th) Hospital of Joint Service Support Force of People' s Liberation Army from January2000 to December 2017. Cases were divided into two groups according to the time of the application of suspended bed. In control group( n = 49),patients started to use suspended bed within 3 days after injury,while suspended beds were put into use from 4 to 6 days after injury in experimental group( n = 58). The following indicators were collected and analyzed: total amount of fluid infusion,amount of colloid liquid,crystal liquid and water,urine volume,resuscitation index in shock stage,visceral complications after injury,hypernatremia,mortality; time of scab formation,time of scab removal,time of wound healing,positive rate of bacterial culture and the incidence of sepsis; time of sand bonding in suspended bed and positive rate of bacterial culture of bed sediment. Date were compared with t test and χ2 test. Results In experimental group,the amount of crystal liquid,colloid liquid,water and total amount of fluid infusion in first 24 hours were( 0. 97 ± 0. 10) m L · kg-1·% TBSA-1,( 0. 67 ± 0. 13) mL·kg~(-1)·% TBSA-1,( 1 233. 00 ± 254. 00) m L,( 2 265. 00 ± 958. 00) m L,and these indicators in first 24 hours in control group were( 1. 18 ± 0. 13) m L · kg-1·% TBSA-1,( 0. 97 ± 0. 10) mL·kg~(-1)·% TBSA-1,( 1 635. 00 ±283. 00) m L,( 2 979. 00 ± 973. 00) m L,the difference between the two groups was statistically significant( t = 9. 585,13. 617,7. 736,3. 811,with P values below 0. 01). The amount of crystal liquid,colloid liquid,water and total amount of fluid infusion in the second 24 hours in experimental group were( 0. 53 ±0. 07) m L· kg-1·% TBSA-1,( 0. 49 ± 0. 06) mL·kg~(-1)·% TBSA-1,( 1 110. 00 ± 229. 00) m L,( 1 755. 00 ± 649. 00) m L; in control group, these indicators in the second 24 hours were( 0. 74 ± 0. 10) mL·kg~(-1)·% TBSA-1,( 0. 75 ± 0. 12) mL·kg~(-1)·% TBSA-1,( 1 542. 00 ±288. 00) m L,( 2 479. 00 ± 771. 00) m L. The amount of fluid in experimental group was significantly lower than that in control group,the difference was statistically significant( t = 12. 529,13. 653,9. 635,5. 279,with P values below 0. 01). The indexes of resuscitation in experimental group were listed following: heart rate( 115. 00 ± 5. 00) beats/min,mean arterial pressure( MAP)( 53. 00 ± 2. 70) mm Hg,central venous pressure( CVP)( 8. 00 ± 0. 80) cm H2 O,lactic acid( 2. 00 ± 0. 60) mmol/L,residual base(-2. 10 ±0. 70) mmol/L,hematocrit( HT)( 0. 42 ± 0. 02) and albumin( 35. 00 ± 1. 40) g/L. The indexes of resuscitation in control group were listed following: heart rate( 126. 00 ± 5. 00) beats/min,MAP( 56. 00 ±3. 30) mm Hg, CVP( 9. 80 ± 1. 50) cm H2 O, lactic acid( 3. 80 ± 0. 60) mmol/L, residual base(-4. 40 ± 0. 60) mmol/L,HT( 0. 53 ± 0. 03) and albumin( 33. 00 ± 2. 10) g/L. These indicators in experimental group were better than those in control group except urine volume, the difference was statistically significant( t = 10. 234,5. 585,8. 214,16. 117,-17. 451,20. 448,-3. 989,with P values below 0. 01). The incidence of hypernatremia and visceral complications in experimental group were 3. 4%and 10. 3% respectively,which were significantly lower than those in control group( 18. 4% and 26. 5%)( χ2= 6. 410,4. 765,with P values below 0. 05),mortality in control group was 4. 1% and 1. 7% in experimental group,there was no significant difference( P > 0. 05). There was no significant difference in the positive rate of bacterial culture and the incidence of sepsis between the two groups( with P values above0. 05). Scab formation in control group was earlier than experimental group,the difference was statistically significant( t =-5. 579,P < 0. 01),however,the time of scab removal and wound healing in experimental group was obviously earlier than control group,the difference was statistically significant( t =-6. 760,4. 212,with P values below 0. 01). In control group,the time of sand bonding was significantly earlier than experimental group,the difference was statistically significant( t =-15. 010,P < 0. 05),and the positive rate of bacterial culture of bed sediment was higher than experimental group,the difference was statistically significant( χ2=4. 356,P < 0. 05). Conclusions The appropriate time for the first application of suspended bed in the treatment of severely burned children should be from 4 to 6 days after injury,which can help the patients get through the shock period successfully and promote wound healing with lower mortality,wound injury and complications.Meanwhile,this timing also can increase the service life and utilization rate of suspended bed.
引文
[1]黄书润,王浩,刘江涛,等.悬浮床在治疗成批烧伤复合伤中的应用[J/CD].中华损伤与修复杂志(电子版),2013,8(3):275-276.
[2]唐贯文,利金彩,周取英,等.悬浮床不同温度对烧伤患儿创面愈合的影响[J].护理学杂志,2009,24(14):4-5.
[3]利金彩,罗连友,朱文娟.重度烧伤小儿应用悬浮床的护理[J].现代护理,2004,10(4):343-344.
[4]游贵方,李纯兰,梁履华,等.悬浮床治疗小儿重度烧伤23例[J].中华烧伤杂志,2004,20(6):370.
[5]盛志勇,郭振荣.危重烧伤治疗与康复学[M].北京:科学出版社,2000:108.
[6]柴家科.实用烧伤外科学[M].北京:人民军医出版社,2014:748.
[7]李济时,周一平,周和平.小儿烧伤[M].北京:人民卫生出版社,1993:24.
[8]左风利,任辉,张家平.限制性液体管理策略防治严重烧伤早期肺脏并发症的临床研究[J].第三军医大学学报,2017,39(8):794-800.
[9]张家平,向飞,童大力,等.限制性液体管理策略对严重烧伤患者早期肺功能影响的对比研究[J].中华烧伤杂志,2012,28(3):165-169.
[10]肖荣,黄跃生,林国安,等.心力扶持对大面积烧伤患者休克延迟复苏的影响[J].中华烧伤杂志,2018,34(1):8-13.
[11] Lu Y,Liu L,Wang J,et al. Controlled blood pressure elevation and limited fluid resuscitation in the treatment of multiple injuries in combination with shock[J]. Pak J Med Sci,2018,34(5):1120-1124.
[12] Gómez BI,He C,Chao T,et al. Effect of Intravenous Fluid Volumes on the Adrenal Glucocorticoid Response After Burn Injury in Swine[J]. J Burn Care Res,2018,39(5):652-660.
[13] Pham TN, Cancio LC, Gibran NS, et al. American Burn Association practice guidelices burn shock resuscitation[J]. J Burn Care Res,2008,29(1):257-266.
[14] Kolarik M,Roberts E. Permissive Hypotension and Trauma:Can Fluid Restriction Reduce the Incidence of ARDS?[J]. J Trauma Nurs,2017,24(1):19-24.
[15]李文军,林国安,赵广贺,等. 911例特重度烧伤患者临床分析[J].实用医药杂志,2017,34(7):595-599.
[16]马玉英.创伤失血性休克的急救与护理[J].内蒙古中医药,2014,33(23):153.
[17]李春燕,邓锦迪,何兴. 200例胃镜检查中心理干预对生命体征影响的研究[J].中国保健营养(下旬刊),2012,22(8):2407-2408.
[18]常新驰,倪娜,曾训庭,等.盐酸右美托咪定用于重症监护室镇静的研究进展[J].世界临床药物,2017,38(10):68-71.
[19]侯建萍,宋青杨,黄继华,等.动态心电图监测航海晕动病对心脏的影响[J].临床心电学杂志,2006,15(5):350-352.
[20]侯建萍,盖晓波.航海运动病发病机制的探讨[J].海军医学杂志,2005,26(4):371-373.
[21]王广,黄跃生,罗中华,等.模拟海上颠簸刺激对严重烧伤家兔心肌力学指标的影响[J].第三军医大学学报,2008,30(8):702-705.
[2]唐贯文,利金彩,周取英,等.悬浮床不同温度对烧伤患儿创面愈合的影响[J].护理学杂志,2009,24(14):4-5.
[3]利金彩,罗连友,朱文娟.重度烧伤小儿应用悬浮床的护理[J].现代护理,2004,10(4):343-344.
[4]游贵方,李纯兰,梁履华,等.悬浮床治疗小儿重度烧伤23例[J].中华烧伤杂志,2004,20(6):370.
[5]盛志勇,郭振荣.危重烧伤治疗与康复学[M].北京:科学出版社,2000:108.
[6]柴家科.实用烧伤外科学[M].北京:人民军医出版社,2014:748.
[7]李济时,周一平,周和平.小儿烧伤[M].北京:人民卫生出版社,1993:24.
[8]左风利,任辉,张家平.限制性液体管理策略防治严重烧伤早期肺脏并发症的临床研究[J].第三军医大学学报,2017,39(8):794-800.
[9]张家平,向飞,童大力,等.限制性液体管理策略对严重烧伤患者早期肺功能影响的对比研究[J].中华烧伤杂志,2012,28(3):165-169.
[10]肖荣,黄跃生,林国安,等.心力扶持对大面积烧伤患者休克延迟复苏的影响[J].中华烧伤杂志,2018,34(1):8-13.
[11] Lu Y,Liu L,Wang J,et al. Controlled blood pressure elevation and limited fluid resuscitation in the treatment of multiple injuries in combination with shock[J]. Pak J Med Sci,2018,34(5):1120-1124.
[12] Gómez BI,He C,Chao T,et al. Effect of Intravenous Fluid Volumes on the Adrenal Glucocorticoid Response After Burn Injury in Swine[J]. J Burn Care Res,2018,39(5):652-660.
[13] Pham TN, Cancio LC, Gibran NS, et al. American Burn Association practice guidelices burn shock resuscitation[J]. J Burn Care Res,2008,29(1):257-266.
[14] Kolarik M,Roberts E. Permissive Hypotension and Trauma:Can Fluid Restriction Reduce the Incidence of ARDS?[J]. J Trauma Nurs,2017,24(1):19-24.
[15]李文军,林国安,赵广贺,等. 911例特重度烧伤患者临床分析[J].实用医药杂志,2017,34(7):595-599.
[16]马玉英.创伤失血性休克的急救与护理[J].内蒙古中医药,2014,33(23):153.
[17]李春燕,邓锦迪,何兴. 200例胃镜检查中心理干预对生命体征影响的研究[J].中国保健营养(下旬刊),2012,22(8):2407-2408.
[18]常新驰,倪娜,曾训庭,等.盐酸右美托咪定用于重症监护室镇静的研究进展[J].世界临床药物,2017,38(10):68-71.
[19]侯建萍,宋青杨,黄继华,等.动态心电图监测航海晕动病对心脏的影响[J].临床心电学杂志,2006,15(5):350-352.
[20]侯建萍,盖晓波.航海运动病发病机制的探讨[J].海军医学杂志,2005,26(4):371-373.
[21]王广,黄跃生,罗中华,等.模拟海上颠簸刺激对严重烧伤家兔心肌力学指标的影响[J].第三军医大学学报,2008,30(8):702-705.