不同液体复苏方式对创伤性休克伴TIC患者的救治效果及免疫调节水平的影响
|
摘要
目的:探讨损伤控制复苏(DCR)与积极液体复苏(AFR)对创伤性休克伴创伤性凝血功能异常(TIC)患者的临床疗效。方法:回顾性分析2011年9月至2017年12月本院收治的92例创伤性休克伴TIC患者的临床资料,依据液体复苏策略分为损伤控制复苏组(DCR组,47例)和积极液体复苏组(AFR组,45例),对复苏前30min、复苏后6h两组活化部分凝血酶原时间(APTT)、国际标准化比值(INR)、血清乳酸(LAC)、红细胞比容(HCT),复苏治疗24h时间段两组休克指数(SI)、平均动脉压(MAP)、血压波动幅度、总补液量,复苏前30mi、复苏后6h、18h、36h时间点两组血小板活化因子(PAF)、磷脂酶A2(PLA2),复苏72h内并发症发生率、复苏后1周存活率等指标进行比较研究。结果:入院时两组MAP、SI、创伤严重度评分(ISS)差异均无统计学意义(P>0.05)。两组患者复苏前30min时间点APTT、INR、LAC、HCT值差异均无统计学意义(P>0.05);复苏后6h时间点APTT、INR、LAC值DCR组显著低于AFR组,HCT值DCR组显著高于AFR组(P <0.05)。复苏治疗24h时间段MAP、血压波动幅度、SI值、总补液量DCR组显著低于AFR组(P<0.05)。复苏前30min时间点、复苏后18h时间点两组PAF、PLA2差异均无统计学意义(P>0.05);复苏后6h时间点DCR组的PAF、PLA2明显高于AFR组、复苏后36h时间点DCR组的PAF、PLA2明显低于AFR组(P <0.05)。复苏72h内ARDS、DIC、MODS发生率DCR组显著低于AFR组、复苏后1周的存活率DCR组显著高于AFR组(P <0.05)。结论:与AFR相比,DCR救治创伤性休克伴TIC患者,改善凝血功能指标,有效纠正休克,复苏期间血压稳定,并发症发生率低,存活率较高,临床优势明显;但在复苏治疗早期AFR能有效抑制免疫细胞因子、炎症介质,具有一定的免疫调节作用。
Objective: To explore the clinical efficacy 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 92 patients with traumatic shock and TIC treated in our hospital from September 2011 to December 2017 were retrospectively analyzed. According to the fluid resuscitation strategy,the patients were divided into the amage control resuscitation group( DCR group,47 cases) and active fluid resuscitation group( AFR group,45 cases). The activated partial thromboplastin time( APTT),international normalized ratio( INR),serum lactate( LAC),and hematocrit( HCT) in the two groups at 30 min before resuscitation and 6 h after resuscitation,and the two groups of shock index( SI),mean arterial pressure( MAP),blood pressure fluctuation amplitude,total fluid volume at 24 hours after resuscitation,platelet activating factor( PAF),Phospholipase A2( PLA2) at 30 min before resuscitation,6 h,18 h,and 36 h after resuscitation,within 72 h of recovery the complication rate and the survival rate at 1 week after resuscitation were compared. Results:There were no significant differences in MAP,SI,and injury severity score( ISS) between the two groups at admission( P >0.05). There was no significant difference in the APTT,INR,LAC,and HCT values between the two groups at 30 min before resuscitation( P >0.05); APTT,INR,LAC values were significantly lower,but HCT values were significantly higher in the DCR group than those in the AFR group at 6 hours after resuscitation( P <0.05). The MAP,blood pressure fluctuation amplitude,SI value,and total rehydration dose in the DCR group were significantly lower than those in the AFR group at 24 hours after resuscitation( P <0.05).There was no significant difference in PAF and PLA2 between the two groups at 30 minutes before and 18 hours after resuscitation( P >0.05). The PAF and PLA2 at 6 hours after resuscitation in the DCR group were significantly higher than those in the AFR group( P <0.05). The PAF and PLA2 at 36 hours after resuscitation were in the DCR group were significantly lower than those in the AFR group( P <0.05). After 72 hours of resuscitation,the incidence of ARDS,DIC,and MODS 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 in the AFR group( P < 0. 05). Conclusion: Compared with AFR,DCR is effective in treating patients with traumatic shock and TIC,improving coagulation function,effectively correcting shock,stable blood pressure during resuscitation,low complication rate,high survival rate,and obvious clinical advantage; but in early resuscitation treatment AFR can effectively inhibit immunocytokines and inflammatory mediators and has a certain degree of immune regulation.
Objective: To explore the clinical efficacy 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 92 patients with traumatic shock and TIC treated in our hospital from September 2011 to December 2017 were retrospectively analyzed. According to the fluid resuscitation strategy,the patients were divided into the amage control resuscitation group( DCR group,47 cases) and active fluid resuscitation group( AFR group,45 cases). The activated partial thromboplastin time( APTT),international normalized ratio( INR),serum lactate( LAC),and hematocrit( HCT) in the two groups at 30 min before resuscitation and 6 h after resuscitation,and the two groups of shock index( SI),mean arterial pressure( MAP),blood pressure fluctuation amplitude,total fluid volume at 24 hours after resuscitation,platelet activating factor( PAF),Phospholipase A2( PLA2) at 30 min before resuscitation,6 h,18 h,and 36 h after resuscitation,within 72 h of recovery the complication rate and the survival rate at 1 week after resuscitation were compared. Results:There were no significant differences in MAP,SI,and injury severity score( ISS) between the two groups at admission( P >0.05). There was no significant difference in the APTT,INR,LAC,and HCT values between the two groups at 30 min before resuscitation( P >0.05); APTT,INR,LAC values were significantly lower,but HCT values were significantly higher in the DCR group than those in the AFR group at 6 hours after resuscitation( P <0.05). The MAP,blood pressure fluctuation amplitude,SI value,and total rehydration dose in the DCR group were significantly lower than those in the AFR group at 24 hours after resuscitation( P <0.05).There was no significant difference in PAF and PLA2 between the two groups at 30 minutes before and 18 hours after resuscitation( P >0.05). The PAF and PLA2 at 6 hours after resuscitation in the DCR group were significantly higher than those in the AFR group( P <0.05). The PAF and PLA2 at 36 hours after resuscitation were in the DCR group were significantly lower than those in the AFR group( P <0.05). After 72 hours of resuscitation,the incidence of ARDS,DIC,and MODS 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 in the AFR group( P < 0. 05). Conclusion: Compared with AFR,DCR is effective in treating patients with traumatic shock and TIC,improving coagulation function,effectively correcting shock,stable blood pressure during resuscitation,low complication rate,high survival rate,and obvious clinical advantage; but in early resuscitation treatment AFR can effectively inhibit immunocytokines and inflammatory mediators and has a certain degree of immune regulation.
引文
[1] 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 Clin,2016,20(1):100.
[2] Epstein D S,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] Aso S,Matsui H J,Fushimi K J,et al.Resuscitative endovascular balloon occlusion ofthe aorta or resuscitative thoracotomy with aortic clamping for non-compressible torso hemorrhage:a retrospective nationwide study[J]. Trauma Acute Care Surg,2017,82(5):910~914.
[4] 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.
[5] Ronald C,John B H. Optimal Fluid Therapy for Traumatic Hemorrhagic shock[J]. Crit Care Clin,2017,33(1):15~36.
[6] Davenport RA,Brohi K. Cause of trauma induced coagulopathy[J]. Curr Opin Anaesthesiol,2016,29(2):212~219.
[7]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.
[8]郝继山,季庆,孙清,等.限制性液体复苏对颅脑损伤合并多发伤的疗效[J].中华创伤杂志,2015,31(2):124~127.
[9] Maitland K,Kiguli S,Opoka R O,et al.Mortality after fluid bolus in African children with severe infeetion[J]N Engl Med,2011,364(26):2483—2495.
[10] White NJ,Wang X,Bradbury N,et al. Fluid resuscitation of uncontrolled hemorrhage using a hemoglobin-based oxygen carrier:effect of traumatic brain injury[J]. Shock,2013,39(2):210~219.
[11] Lipsky AM,Ganor O,Abramovich A,et al. Walking between the drops:lsraeli defense forces fluid resuscitation protocol[J].Emerg Med,2013,44(4):790~795.
[12]吴敏,龙静,杨瑶.自体输血与异体输血对择期手术患者凝血功能及免疫功能的影响[J].河北医学,2017,23(7):1170~1173.
[13] 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 D S,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] Aso S,Matsui H J,Fushimi K J,et al.Resuscitative endovascular balloon occlusion ofthe aorta or resuscitative thoracotomy with aortic clamping for non-compressible torso hemorrhage:a retrospective nationwide study[J]. Trauma Acute Care Surg,2017,82(5):910~914.
[4] 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.
[5] Ronald C,John B H. Optimal Fluid Therapy for Traumatic Hemorrhagic shock[J]. Crit Care Clin,2017,33(1):15~36.
[6] Davenport RA,Brohi K. Cause of trauma induced coagulopathy[J]. Curr Opin Anaesthesiol,2016,29(2):212~219.
[7]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.
[8]郝继山,季庆,孙清,等.限制性液体复苏对颅脑损伤合并多发伤的疗效[J].中华创伤杂志,2015,31(2):124~127.
[9] Maitland K,Kiguli S,Opoka R O,et al.Mortality after fluid bolus in African children with severe infeetion[J]N Engl Med,2011,364(26):2483—2495.
[10] White NJ,Wang X,Bradbury N,et al. Fluid resuscitation of uncontrolled hemorrhage using a hemoglobin-based oxygen carrier:effect of traumatic brain injury[J]. Shock,2013,39(2):210~219.
[11] Lipsky AM,Ganor O,Abramovich A,et al. Walking between the drops:lsraeli defense forces fluid resuscitation protocol[J].Emerg Med,2013,44(4):790~795.
[12]吴敏,龙静,杨瑶.自体输血与异体输血对择期手术患者凝血功能及免疫功能的影响[J].河北医学,2017,23(7):1170~1173.
[13] 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.
© 2004-2018 中国地质图书馆版权所有 京ICP备05064691号 京公网安备11010802017129号 地址：北京市海淀区学院路29号 邮编：100083 电话：办公室：(+86 10)66554848；文献借阅、咨询服务、科技查新：66554700 |