口服ORS液复合卡巴胆碱复苏烧伤休克的实验研究
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摘要
目的
1、研究和比较口服补液与静脉补液对烧伤休克循环指标和存活率的影响,评价早期口服补液治疗烧伤休克的作用和效果;2、研究口服ORS液复合卡巴胆碱对烧伤休克时胃肠功能的保护作用,为研制合理的口服液配方,提高口服补液的疗效提供实验依据。
材料和方法
烧伤模型制作:健康雄性杂种犬32条,术前禁食12h。氯胺酮(8mg/kg)+速眠新Ⅱ(0.1mg/kg)肌肉注射麻醉。将10#硅胶动脉导管和8#硅胶静脉导管分别插入股动脉和股静脉,动脉导管与CARDIOMAX型血流动力学监测仪连接,静脉导管用于静脉补液。在胃窦部近幽门口约5cm处造口,顺胃大弯置入16F胃粘膜张力计(Datex-Ohmeda芬兰,带有营养通道);于空肠距Treiz韧带10-15cm处造口,放置肠内测压管。在犬整个背部(约30%TBSA)均匀涂3%凝固汽油4遍,火焰烧50秒后用湿布扑灭。
分组及复苏方案:动物随机分为不复苏组(NR)、静脉林格氏液复苏组(LVR)、口服ORS(oral rehydration salt)液组(OR)、口服ORS液+卡巴胆碱组(OR+K)。NR组:30%TBSA烧伤后口服和静脉均不补液。LVR组:烧伤后半小时开始,按Parkland公式(4ml.kg~(-1).%TBSA~(-1))通过静脉导管补液。前8小时用ZNB-XB型输液泵匀速输入一半的量,其后16小时匀速输入余下液体。第二天在16小时内经静脉导管匀速输入全天液量。OR组:烧伤后半小时开始,按Parkland公式(4ml.kg~(-1).%TBSA~(-1))通过胃粘膜张力计的营养通道给予ORS液,即前8小时分三次补全天量的一半,其后16小时用ZNB-XB型输液泵(中科院力学研究所)匀速输入剩余液体。第二天在16小时内经营养通道匀速注入全天液量。OR+K组:除口服补液方式同OR组外,还经胃粘膜张力计的营养通道口服卡巴胆碱2次/日,剂量为0.025mg.Kg~(-1).24h~(-1)。
结果
1、烧伤3小时后不补液组MAP显著降低,两口服补液组MAP低于静脉补液组,但高于不补液组(P＜0.05),两口服补液组之间无显著性差异(P＞0.05)。
2、烧伤3小时后OR组和OR+K组的胃pHi显著高于NR组,但低于LVR组(P＜0.05);OR+K组的pHi显著高于OR组(P＜0.05)。
3、烧伤后LVR组的IP无显著性变化,NR组逐渐增高;OR组IP的升高较OR+K组明显,伤后3小时后两者有显著差异(P＜0.05)。
4、烧伤后NR组DAO持续增高:LVR组DAO复苏后逐渐恢复至正常;OR组DAO增高较OR+K组明显,伤后9小时有显著差异(P＜0.05)。
5、烧伤后各组D-乳酸均增高,其中NR组显著高于其它各组,OR组和OR+K组无显著差异(P＞0.05)。
6、OR组和OR+K组24小时、48小时尿量高于NR组,但低于LVR组(P＜0.05)。NR组24、48小时死亡率为62.5%和100%,明显高于OR组、OR+K组和LVR组(P＜0.05)。
7、OR组4只动物出现呕吐(4/8),呕吐量70-505ml,胃内平均残留液体量为346.3±142.2ml;OR+K组2只动物出现呕吐(2/8),呕吐量在55-120之间,胃内平均残留液体量为185.6±78.3,两组差异有显著性(P＜0.05)。NR组2只动物出现呕吐(2/8),呕吐量在40-125ml之间,胃内平均残留液体量为83.1±22.2ml;LVR组1只动物出现呕吐(1/8),呕吐量为30ml,胃内平均残留液体量为71.9±20.7ml,两组无显著性差异(P＞0.05)。
结论
1、早期口服补液能有效改善30%TBSAⅢ~0烧伤的血压和尿量,恢复胃肠血液灌流,显著提高烧伤休克的存活率,在伤后48小时内可基本替代静脉液体复苏。
2、烧伤休克能显著降低胃肠对口服液体的耐受性,表现为呕吐、肠粘膜损伤和肠内压显著增高。
3、采用ORS液复合卡巴胆碱复苏烧伤休克能显著改善胃肠功能,提高胃肠对早期口服液体的耐受能力及烧伤休克的复苏效果。
Objective
1.To perform a comparative study of effects of oral rehydration to vein rehydration on circulatoey parameters and survival rate in dogs with burns shock;2.To investigate the protective role of oral rehydration salt combined with carbachol on gastrointestinal function so as to develop a reasonable compounding of oral rehydration and improve therapeutic effect of oral rehydration in resuscitation of burns shock.
Materials and methods
Burns model:Thirty-two health male dogs were used in the study.Animals were fasted 16 hours before surgery and anesthetized by intramuscular injection of ketamine(8mg/kg) and tacho-sleepⅡ(0.1mg/kg).Catheters were placed into the femoral artery and vein for monitoring hemodynamic parameters and infusing fluid.Gastrotomy was done to insert a tonometer for the measurement of pHi.A catheter was put through a small enterotomy on jejunal 10-15cm near Treiz ligament for measurement of intestinal cavity pressure.On back body of dogs(about 30%TBSA) was overlaid uniformly with 3%napalm four times,then blanketed after burning 50 seconds.
Group and resuscitative project:Dogs were divided into four groups:Burns with no resuscitation(NR),burns+intravenous infusion of Ringer's solution(LVR,4ml.kg~(-1). %TBSA~(-1)),burns+oral rehydration salt(OR),burns+oral rehydration salt combined with carbachol(OR+K).In first eight hours,a half of 24 hours volume of Ringer's solution (according to Parkland formula) was intravenously given to animals in LVR group,the rest fluids were given in left sixteen hours.On the next day,all volume of Ringer's solution was intravenously given to animals in sixteen hours.all Animals in OR group were enterally resuscitated with ORS fluid through a gastric tonometer begging from 0.5 h post burn(first given three times in eight hours,the rest given in left sixteen hours).On the next day,all volume of ORS fluid was given to animals through a gastric tonometer in sixteen hours.In OR+K group resuscitative project was performed as same as OR group except given carbachol enterally two times per day at dose of 0.025mg.kg~(-1).24hr.
Results
1.MAP in two groups of fluid replacement significantly decreased at three hours post burn.MAP were much lower in two oral rehydration groups than that in venous rehydration group(P＜0.05),but higher than that in NR group(P＜0.05),there was no significant differences between oral rehydration only and oral rehydration+carbachol(P＞0.05).
2.Gastric mucosa pHi were higher in groups of OR and OR+K than that in NR group three hours post burn.,but lower than that in LVR group(P＜0.05).Gastric mucosa pHi was higher in OR+K group than that inOR group(P＜0.05).
3.Intestinal pressure was not significantly changed in LVR group,while it did increase gradually in NR group compared with that before injury.Intestinal pressure was obviously higher in OR group than that in OR+K group at three hours post burn(P＜0.05).
4.The changes of plasma DAO and D-lactic acid in all groups was significantly increased post burn,and gradually fall off after resuscitation accept NR group.It were much lower in OR+K group than those in OR group(P＜0.05),and higher than those in LVR group post burn(P＜0.05)
5.The urinary volumes of 24h and 48h in OR and OR+K groups were much higher than those in NR group,and lower than those in LVR group.Mortality rate of 24 h and 48h were significantly higher with 62.5%and 100%in NR group than those in other three resuscitated groups(P＜0.05).
6.Four of eight dogs in OR group vomited about 70-505ml with 346.3±142.2ml of residual fluid in stomach,which were significantly higher than those in OR+K group(two of eight dogs vomited about 55-120ml with 185.6±78.3ml of residual fluid in stomach P＜0.05).There were no significant differences in incidence and severity of vomiting and gastric residual fluid between NR group and LVR group(P＞0.05)
Conclusion
1.Early oral rehydration has significant improvements on mean artery pressure, gastrointestinal perfusion and survival rats in dogs with 30%TBSAⅢ°burn injury,which almost substitute the effects of venous resuscitation in 48 hours post burn.
2.Burns shock may result in decreased gut tolerance to oral rehydration,manifesting sever vomiting,gut mucosa damage and elevation of intestinal cavity pressure,which were closely correlated with higher gastrointestinal pHi.
3.Enteral treatment of carbachol in resuscitation of burns shock significantly improve gut tolerance to oral rehydration salt by increasing gut motor and absorption,and alleviating pathological injury
1、研究和比较口服补液与静脉补液对烧伤休克循环指标和存活率的影响,评价早期口服补液治疗烧伤休克的作用和效果;2、研究口服ORS液复合卡巴胆碱对烧伤休克时胃肠功能的保护作用,为研制合理的口服液配方,提高口服补液的疗效提供实验依据。
材料和方法
烧伤模型制作:健康雄性杂种犬32条,术前禁食12h。氯胺酮(8mg/kg)+速眠新Ⅱ(0.1mg/kg)肌肉注射麻醉。将10#硅胶动脉导管和8#硅胶静脉导管分别插入股动脉和股静脉,动脉导管与CARDIOMAX型血流动力学监测仪连接,静脉导管用于静脉补液。在胃窦部近幽门口约5cm处造口,顺胃大弯置入16F胃粘膜张力计(Datex-Ohmeda芬兰,带有营养通道);于空肠距Treiz韧带10-15cm处造口,放置肠内测压管。在犬整个背部(约30%TBSA)均匀涂3%凝固汽油4遍,火焰烧50秒后用湿布扑灭。
分组及复苏方案:动物随机分为不复苏组(NR)、静脉林格氏液复苏组(LVR)、口服ORS(oral rehydration salt)液组(OR)、口服ORS液+卡巴胆碱组(OR+K)。NR组:30%TBSA烧伤后口服和静脉均不补液。LVR组:烧伤后半小时开始,按Parkland公式(4ml.kg~(-1).%TBSA~(-1))通过静脉导管补液。前8小时用ZNB-XB型输液泵匀速输入一半的量,其后16小时匀速输入余下液体。第二天在16小时内经静脉导管匀速输入全天液量。OR组:烧伤后半小时开始,按Parkland公式(4ml.kg~(-1).%TBSA~(-1))通过胃粘膜张力计的营养通道给予ORS液,即前8小时分三次补全天量的一半,其后16小时用ZNB-XB型输液泵(中科院力学研究所)匀速输入剩余液体。第二天在16小时内经营养通道匀速注入全天液量。OR+K组:除口服补液方式同OR组外,还经胃粘膜张力计的营养通道口服卡巴胆碱2次/日,剂量为0.025mg.Kg~(-1).24h~(-1)。
结果
1、烧伤3小时后不补液组MAP显著降低,两口服补液组MAP低于静脉补液组,但高于不补液组(P＜0.05),两口服补液组之间无显著性差异(P＞0.05)。
2、烧伤3小时后OR组和OR+K组的胃pHi显著高于NR组,但低于LVR组(P＜0.05);OR+K组的pHi显著高于OR组(P＜0.05)。
3、烧伤后LVR组的IP无显著性变化,NR组逐渐增高;OR组IP的升高较OR+K组明显,伤后3小时后两者有显著差异(P＜0.05)。
4、烧伤后NR组DAO持续增高:LVR组DAO复苏后逐渐恢复至正常;OR组DAO增高较OR+K组明显,伤后9小时有显著差异(P＜0.05)。
5、烧伤后各组D-乳酸均增高,其中NR组显著高于其它各组,OR组和OR+K组无显著差异(P＞0.05)。
6、OR组和OR+K组24小时、48小时尿量高于NR组,但低于LVR组(P＜0.05)。NR组24、48小时死亡率为62.5%和100%,明显高于OR组、OR+K组和LVR组(P＜0.05)。
7、OR组4只动物出现呕吐(4/8),呕吐量70-505ml,胃内平均残留液体量为346.3±142.2ml;OR+K组2只动物出现呕吐(2/8),呕吐量在55-120之间,胃内平均残留液体量为185.6±78.3,两组差异有显著性(P＜0.05)。NR组2只动物出现呕吐(2/8),呕吐量在40-125ml之间,胃内平均残留液体量为83.1±22.2ml;LVR组1只动物出现呕吐(1/8),呕吐量为30ml,胃内平均残留液体量为71.9±20.7ml,两组无显著性差异(P＞0.05)。
结论
1、早期口服补液能有效改善30%TBSAⅢ~0烧伤的血压和尿量,恢复胃肠血液灌流,显著提高烧伤休克的存活率,在伤后48小时内可基本替代静脉液体复苏。
2、烧伤休克能显著降低胃肠对口服液体的耐受性,表现为呕吐、肠粘膜损伤和肠内压显著增高。
3、采用ORS液复合卡巴胆碱复苏烧伤休克能显著改善胃肠功能,提高胃肠对早期口服液体的耐受能力及烧伤休克的复苏效果。
Objective
1.To perform a comparative study of effects of oral rehydration to vein rehydration on circulatoey parameters and survival rate in dogs with burns shock;2.To investigate the protective role of oral rehydration salt combined with carbachol on gastrointestinal function so as to develop a reasonable compounding of oral rehydration and improve therapeutic effect of oral rehydration in resuscitation of burns shock.
Materials and methods
Burns model:Thirty-two health male dogs were used in the study.Animals were fasted 16 hours before surgery and anesthetized by intramuscular injection of ketamine(8mg/kg) and tacho-sleepⅡ(0.1mg/kg).Catheters were placed into the femoral artery and vein for monitoring hemodynamic parameters and infusing fluid.Gastrotomy was done to insert a tonometer for the measurement of pHi.A catheter was put through a small enterotomy on jejunal 10-15cm near Treiz ligament for measurement of intestinal cavity pressure.On back body of dogs(about 30%TBSA) was overlaid uniformly with 3%napalm four times,then blanketed after burning 50 seconds.
Group and resuscitative project:Dogs were divided into four groups:Burns with no resuscitation(NR),burns+intravenous infusion of Ringer's solution(LVR,4ml.kg~(-1). %TBSA~(-1)),burns+oral rehydration salt(OR),burns+oral rehydration salt combined with carbachol(OR+K).In first eight hours,a half of 24 hours volume of Ringer's solution (according to Parkland formula) was intravenously given to animals in LVR group,the rest fluids were given in left sixteen hours.On the next day,all volume of Ringer's solution was intravenously given to animals in sixteen hours.all Animals in OR group were enterally resuscitated with ORS fluid through a gastric tonometer begging from 0.5 h post burn(first given three times in eight hours,the rest given in left sixteen hours).On the next day,all volume of ORS fluid was given to animals through a gastric tonometer in sixteen hours.In OR+K group resuscitative project was performed as same as OR group except given carbachol enterally two times per day at dose of 0.025mg.kg~(-1).24hr.
Results
1.MAP in two groups of fluid replacement significantly decreased at three hours post burn.MAP were much lower in two oral rehydration groups than that in venous rehydration group(P＜0.05),but higher than that in NR group(P＜0.05),there was no significant differences between oral rehydration only and oral rehydration+carbachol(P＞0.05).
2.Gastric mucosa pHi were higher in groups of OR and OR+K than that in NR group three hours post burn.,but lower than that in LVR group(P＜0.05).Gastric mucosa pHi was higher in OR+K group than that inOR group(P＜0.05).
3.Intestinal pressure was not significantly changed in LVR group,while it did increase gradually in NR group compared with that before injury.Intestinal pressure was obviously higher in OR group than that in OR+K group at three hours post burn(P＜0.05).
4.The changes of plasma DAO and D-lactic acid in all groups was significantly increased post burn,and gradually fall off after resuscitation accept NR group.It were much lower in OR+K group than those in OR group(P＜0.05),and higher than those in LVR group post burn(P＜0.05)
5.The urinary volumes of 24h and 48h in OR and OR+K groups were much higher than those in NR group,and lower than those in LVR group.Mortality rate of 24 h and 48h were significantly higher with 62.5%and 100%in NR group than those in other three resuscitated groups(P＜0.05).
6.Four of eight dogs in OR group vomited about 70-505ml with 346.3±142.2ml of residual fluid in stomach,which were significantly higher than those in OR+K group(two of eight dogs vomited about 55-120ml with 185.6±78.3ml of residual fluid in stomach P＜0.05).There were no significant differences in incidence and severity of vomiting and gastric residual fluid between NR group and LVR group(P＞0.05)
Conclusion
1.Early oral rehydration has significant improvements on mean artery pressure, gastrointestinal perfusion and survival rats in dogs with 30%TBSAⅢ°burn injury,which almost substitute the effects of venous resuscitation in 48 hours post burn.
2.Burns shock may result in decreased gut tolerance to oral rehydration,manifesting sever vomiting,gut mucosa damage and elevation of intestinal cavity pressure,which were closely correlated with higher gastrointestinal pHi.
3.Enteral treatment of carbachol in resuscitation of burns shock significantly improve gut tolerance to oral rehydration salt by increasing gut motor and absorption,and alleviating pathological injury
引文
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11.Sato A,Kuwabara Y,Sugiura M et al.intestinal energy metabolism during ischemia and reperfusion.J Surg Res,1999,82:261
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13.Singh G,Chaudry KL,Chudler LC et al.Depressed gut absorptive capacity early after trauma-hemorrhagic shock.Ann Surg,1991,214:712
14.Singh G,Harkema JM,Mayberry AJ et al.Severe depression of gut absorptive capacity in patients following trauma or sepsis.J Trauma,1994,36:803
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20.Souba WW,Wilmore DW.Postoperative alteration of arteriovenous exchange of amino acids across the gastrointestinal tract.Surgery,1983,94:342
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1.曹卫红,胡森,孙丹等.肠道部分缺血再灌注损伤动物模型的复制.创伤外科杂志,2005,1(1):11
2.Morris SE,Navaratnam N,Herndon DN.A comparison of erects of thermal injury and smoke inhalation on bacterial translocation.J Trauma,199o,30:636
3.Tadros T,Traber DL,Heggers JP et al.Angiotension Ⅱ inhibitor DUP753 attenuates burn and endotoxin-induced gut ischemia,lipid peroxidation,mucosal permeability and bacterial translocation.Ann Surg,200,231:566
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5.杨红明,柴家科,盛志勇等.严重烧伤延迟复苏后多器官功能障碍综合征的早期防治.中国危重病急救医学,2000,12(10):610
6.Minami H,MeCallum RW.The physiology and pathophysiology of gastric emptying humans.Gastroenterology,1984,86:1592
7.Costill DL,Saltin B.Factors limiting gastric emptying during rest and exercise.J Appl Physiol,1974,37:679
8.Maughan RJ.Optimizing hydration in competitive sport.in:Lamb DR,Williams MH,Murray Reds.Perspectives in exercise sciences and sports medicine performance.Vol 10.Carmel:Benchmark Press,1991.139
9.Thomas SJ,Kramer GC,Hermdon DN.Burns:military options and tactical solutions.J Trauma,2003,54(5):S207
10.Meinild AK,Klaerke D,Loo DDF et al.The human Na~+/glucose cotransporter is a molecular water pump.J Physiol,1998,508:15
11.Sato A,Kuwabara Y,Sugiura M et al.intestinal energy metabolism during ischemia and reperfusion.J Surg Res,1999,82:261
12.Way V,Dhar A,Reddy R et al.Changes in adenine nucleotides during hemorrhagic shock and reperfused in testine in rats.Surg Today,1998,28:177
13.Singh G,Chaudry KL,Chudler LC et al.Depressed gut absorptive capacity early after trauma-hemorrhagic shock.Ann Surg,1991,214:712
14.Singh G,Harkema JM,Mayberry AJ et al.Severe depression of gut absorptive capacity in patients following trauma or sepsis.J Trauma,1994,36:803
15.Chou CC,Kvietys PR,Post J et al.Constiuents of chyme responsible for postprandial intestinal hyperemia.Am J Physiol,1978,235:H677
16.Singh G,Chaudry KI,Chaudry IH.ATP-MgCL_2 restores gut absorptive capacity early after trauma-hemorrhagic shock.Am J physiol,1993,264:R977
17.Singh G.Chaudry KI,Chudler LC et al.Sepsis produces early depression of gut absorptive capacity:restoration with diltiazem treatment.Am J Physiol,1992,263(1Pt2):R19
18.胡森,盛志勇,柳琪琳等.大鼠小肠缺血-再灌注时肠内给予不同营养物对肠粘粘膜吸收功能和能量代谢的影响.中华医学杂志,2002,82(10):689
19.余斌,汪仕良,尤忠义等.谷氨酰胺对严重烧伤猪肠道吸收功能的作用.中华外科杂志,1995,33(12):742
20.Souba WW,Wilmore DW.Postoperative alteration of arteriovenous exchange of amino acids across the gastrointestinal tract.Surgery,1983,94:342
21.Monofo WW.The treament of burn shock by the intravenous and oral administration of hypertonic lactated saline solution.J Trauma,1970,10:575
22.姜坤元,黎鳌,杨宗城等.30%浅Ⅱ~0烧伤口服补液复苏的实验研究.中华整形烧伤外科杂志,1988,4(4):288
23.Ramakrishna B.Towards a better oral rehydration fluid.Indian J pediatr,2001,68:41
24.Sladen G.Methods of studying intestinal absorption in man.In:Mcoll I,Sladen G eds.Intestinal absorption in man.London:Academic Press,1975.1
25.Brown TLH,Owens CHB.Incidence of vomiting in bums and implications for mass burn casualty management.Bums,2003,29(1):159