不同液体复苏策略在创伤性休克伴创伤性凝血功能异常患者中的应用研究
|
摘要
目的探究损伤控制复苏(DCR)与积极液体复苏(AFR)在创伤性休克伴创伤性凝血功能异常(TIC)患者中应用的临床价值。方法回顾性分析2011年3月——2017年9月我院收治的128例创伤性休克伴TIC患者的临床资料,根据液体复苏策略分为损伤控制复苏组(DCR组,65例)、积极液体复苏组(AFR组,63例),对复苏前后基础资料、血压、液体量、凝血功能、休克功能、免疫介质、救治效果等指标进行比较研究。结果入院时二组基础资料差异均无统计学意义(P>0.05)。二组患者复苏前15 min血小板(PLT)、国际标准化比值(INR)、血清乳酸(LAC)、红细胞比容(HCT)值差异均无统计学意义(P>0.05);复苏后12 h时间点INR、LAC值DCR组显著低于AFR组,PLT、HCT值DCR组显著高于AFR组(P<0.05)。复苏治疗18 h时间段平均动脉压、休克指数、血压波动幅度、总补液量DCR组显著低于AFR组,血红蛋白值DCR组显著高于AFR组(P<0.05)。复苏前15 min时间点、复苏后24 h时间点二组肿瘤坏死因子(TNF-α)、白细胞介素-6(IL-6)差异均无统计学意义(P>0.05);复苏后12 h时间点DCR组TNF-α、IL-6明显高于AFR组,复苏后36 h时间点DCR组TNF-α、IL-6明显低于AFR组(P<0.05)。复苏96 h内并发症发生率DCR组显著低于AFR组、复苏后1周存活率DCR组显著高于AFR组(P<0.05)。结论 DCR救治创伤性休克伴TIC患者,有效纠正休克及改善凝血功能,临床价值显著;但AFR在治疗早期能有效抑制免疫介质,具有一定的免疫调节作用。
Objective To explore the clinical value of damage control resuscitation(DCR) and active fluid resuscitation(AFR)in patients with traumatic shock and trauma induced coagulopathy(TIC).Methods The clinical data of one hundred and twenty-eight patients with traumatic shock and TIC treated in Chengde Medical College Affiliated Hospital from March 2011 to September 2017 were retrospectively analyzed.According to the fluid resuscitation strategy,the patients were divided into the damage control resuscitation group(DCR group,65 cases) and active fluid resuscitation group(AFR group,63 cases) to compare the indicators before and after resuscitation.Results There was no significant difference in the baseline data between the two groups at admission(P>0.05).There was no significant difference in the INR,PLT,LAC,and HCT values between the two groups at 15 min before resuscitation(P>0.05);At 12 hours after resuscitation,the INR and LAC values were significantly lower in the DCR group than those in the AFR group,while the PLT and HCT values were significantly higher in the DCR group than those in the AFR group(P<0.05).In18 h after resuscitation,the MAP,blood pressure fluctuation amplitude,SI,total fluid volume dose in the DCR group were significantly lower than those in the AFR group,while the Hb values were significantly higher in the DCR group than that in the AFR group(P<0.05).There was no significant difference in TNF-αand IL-6 between the two groups at 15 min before and 24 h after resuscitation(P>0.05).The TNF-αand IL-6 at 12 h after resuscitation in the DCR group were significantly higher than those in the AFR group,while the TNF-αand IL-6 at 36 hours after resuscitation were in the DCR group were significantly lower than those in the AFR group(P<0.05).After 96 h of resuscitation,the incidence of complication was significantly lower in the DCR group than in the AFR group,and the survival rate after one week of resuscitation was significantly higher in the DCR group than that in the AFR group(P<0.05).Conclusion DCR can effectively correct shock and improve coagulation function in the treatment of traumatic shock patients with TIC.However,AFR can effectively inhibit immune mediators in the early stage of treatment and has certain immunoregulatory effect.
Objective To explore the clinical value of damage control resuscitation(DCR) and active fluid resuscitation(AFR)in patients with traumatic shock and trauma induced coagulopathy(TIC).Methods The clinical data of one hundred and twenty-eight patients with traumatic shock and TIC treated in Chengde Medical College Affiliated Hospital from March 2011 to September 2017 were retrospectively analyzed.According to the fluid resuscitation strategy,the patients were divided into the damage control resuscitation group(DCR group,65 cases) and active fluid resuscitation group(AFR group,63 cases) to compare the indicators before and after resuscitation.Results There was no significant difference in the baseline data between the two groups at admission(P>0.05).There was no significant difference in the INR,PLT,LAC,and HCT values between the two groups at 15 min before resuscitation(P>0.05);At 12 hours after resuscitation,the INR and LAC values were significantly lower in the DCR group than those in the AFR group,while the PLT and HCT values were significantly higher in the DCR group than those in the AFR group(P<0.05).In18 h after resuscitation,the MAP,blood pressure fluctuation amplitude,SI,total fluid volume dose in the DCR group were significantly lower than those in the AFR group,while the Hb values were significantly higher in the DCR group than that in the AFR group(P<0.05).There was no significant difference in TNF-αand IL-6 between the two groups at 15 min before and 24 h after resuscitation(P>0.05).The TNF-αand IL-6 at 12 h after resuscitation in the DCR group were significantly higher than those in the AFR group,while the TNF-αand IL-6 at 36 hours after resuscitation were in the DCR group were significantly lower than those in the AFR group(P<0.05).After 96 h of resuscitation,the incidence of complication was significantly lower in the DCR group than in the AFR group,and the survival rate after one week of resuscitation was significantly higher in the DCR group than that in the AFR group(P<0.05).Conclusion DCR can effectively correct shock and improve coagulation function in the treatment of traumatic shock patients with TIC.However,AFR can effectively inhibit immune mediators in the early stage of treatment and has certain immunoregulatory effect.
引文
[1]Leman P,Morley P.Review article:Updated resuscitation guidelines for 2016:A summary of the Australian and New Zealand Committee on Resuscitation recommendations[J].Emerg Med Australas,2016,28(4):379-382
[2]Epstein DS,Mitra B,O’Reilly G,et al.Acute traumatic coagulopathy in the setting of isolated traumatic brain injury:a systematic review and meta analysis[J].Injury,2014,45(5):819-824
[3]Kragh JF Jr,Dubick M A,Aden J K,et al.U.S.Military experience from 2001 to 2010 with extremity fasciotomy in war surgery[J].Mil Med,2016,181(5):463-468
[4]史云光,张志刚,张瑞英,等.多发伤患者凝血功能指标在病情程度及预后判断中的作用研究[J].海军医学,2017,38(2):170-174
[5]Tobin J M,Tanaka K A,Smith C E.Factor concentrates in trauma[J].Curr Opin Anaesthesiol,2015,28(2):217-226
[6]王守君,翟萍,王世富.床旁超声指导感染性休克患者液体复苏的研究[J].中国煤炭工业医学杂志,2016,19(12):1709-1712
[7]Ronald C,John B H.Optimal Fluid Therapy for Traumatic Hemorrhagic shock[J].Crit Care Clin,2017,33(1):15-36
[8]周文龙,吴莹,李占明,等.脉搏灌注指数变异指导液体复苏对低血容量性休克患者预后的影响[J].中国煤炭工业医学杂志,2014,(11):1785-1787
[9]张宪,刘红升,姚咏明,等.创伤失血性休克限制性液体复苏中急诊监测的临床意义[J].中国急救医学,2015,35(12):1097-1099
[10]Davenport RA,Brohi K.Cause of trauma induced coagulopathy[J].Curr Opin Anaesthesiol,2016,29(2):212-219
[11]Maegele M,Schochl H,Cohen MJ.An update on the coagulopathy of trauma[J].Shock,2014,41(Suppl 1):21-25
[12]Lipsky AM,Ganor O,Abramovich A,et al.Walking between the drops:lsraeli defense forces fluid resuscitation protocol[J].J Emerg Med,2013,44(4):790-795
[13]Cohen MJ,Call M,Nelson M,et al.Critical role of activated protein C in early coagulopathy and later organ failure,infection and death in trauma patients[J].Ann Stag,2012,255(2):379-385
[14]李晓燕,黄维维,张强.LPS、IL-6和CRP在肺炎合并脓毒血症中的临床意义[J].中国煤炭工业医学杂志,2018,21(5):473-477
[15]李志伟,王著军,徐旭,等.TNF-α、LPS、IL-6、PFA与重症胸腹损伤凝血功能障碍的相关性研究[J].国际外科杂志,2013,40(8):526-529
[16]De S F,Solito S,Ugel S,et al.MDSCs in cancer:Conceiving new prognostic and therapeutic targets[J].Biochimica Et Biophysica Acta,2015,1865(1):35-48
[2]Epstein DS,Mitra B,O’Reilly G,et al.Acute traumatic coagulopathy in the setting of isolated traumatic brain injury:a systematic review and meta analysis[J].Injury,2014,45(5):819-824
[3]Kragh JF Jr,Dubick M A,Aden J K,et al.U.S.Military experience from 2001 to 2010 with extremity fasciotomy in war surgery[J].Mil Med,2016,181(5):463-468
[4]史云光,张志刚,张瑞英,等.多发伤患者凝血功能指标在病情程度及预后判断中的作用研究[J].海军医学,2017,38(2):170-174
[5]Tobin J M,Tanaka K A,Smith C E.Factor concentrates in trauma[J].Curr Opin Anaesthesiol,2015,28(2):217-226
[6]王守君,翟萍,王世富.床旁超声指导感染性休克患者液体复苏的研究[J].中国煤炭工业医学杂志,2016,19(12):1709-1712
[7]Ronald C,John B H.Optimal Fluid Therapy for Traumatic Hemorrhagic shock[J].Crit Care Clin,2017,33(1):15-36
[8]周文龙,吴莹,李占明,等.脉搏灌注指数变异指导液体复苏对低血容量性休克患者预后的影响[J].中国煤炭工业医学杂志,2014,(11):1785-1787
[9]张宪,刘红升,姚咏明,等.创伤失血性休克限制性液体复苏中急诊监测的临床意义[J].中国急救医学,2015,35(12):1097-1099
[10]Davenport RA,Brohi K.Cause of trauma induced coagulopathy[J].Curr Opin Anaesthesiol,2016,29(2):212-219
[11]Maegele M,Schochl H,Cohen MJ.An update on the coagulopathy of trauma[J].Shock,2014,41(Suppl 1):21-25
[12]Lipsky AM,Ganor O,Abramovich A,et al.Walking between the drops:lsraeli defense forces fluid resuscitation protocol[J].J Emerg Med,2013,44(4):790-795
[13]Cohen MJ,Call M,Nelson M,et al.Critical role of activated protein C in early coagulopathy and later organ failure,infection and death in trauma patients[J].Ann Stag,2012,255(2):379-385
[14]李晓燕,黄维维,张强.LPS、IL-6和CRP在肺炎合并脓毒血症中的临床意义[J].中国煤炭工业医学杂志,2018,21(5):473-477
[15]李志伟,王著军,徐旭,等.TNF-α、LPS、IL-6、PFA与重症胸腹损伤凝血功能障碍的相关性研究[J].国际外科杂志,2013,40(8):526-529
[16]De S F,Solito S,Ugel S,et al.MDSCs in cancer:Conceiving new prognostic and therapeutic targets[J].Biochimica Et Biophysica Acta,2015,1865(1):35-48