回吸收期RFMS防治大面积烧伤肺脏并发症的临床研究
发布时间：2018-07-15 17:04
【摘要】：背景及目的大面积烧伤患者早期由于身体各器官病理生理的改变,并发症多,而肺脏并发症发生率最高。大面积烧伤早期易发生肺水肿,肺水肿是肺部感染、急性呼吸窘迫综合征(ARDS)或呼吸功能障碍等的重要诱因,可致患者多器官功能衰竭(MODS)甚至死亡,对大面积烧伤患者的转归和预后有重要影响。传统的肺水监测方法不能准确测量血管外肺水含量,且操作复杂,临床实用性不高,使大面积烧伤患者早期肺水的监测和防治受限。有研究指出血管外肺水含量与肺水肿成正相关,肺水肿的程度可以通过血管外肺水含量来量化[1]。脉搏轮廓持续心输出量(pulse indicator continuous cardiac output,PICCO)容量监测仪可床旁定量监测患者血管外肺水含量,是目前能床旁动态定量监测肺水含量的唯一新技术。课题组前期采用PICCO连续监测意外发现,大面积烧伤患者进入回吸收期(伤后3-10天),血管外肺水肿指数(ELWI)呈持续性增高的状态,且均高于正常高值(7mL/kg),说明在现有的治疗模式下大面积烧伤早期均存在不同程度的肺水肿。进一步分析,发现大面积烧伤早期肺功能与ELWI呈显著负相关。上述研究揭示了大面积烧伤患者早期肺水变化规律及其可能临床意义。限制性液体管理策略(restrictive fluid management strategy,RFMS)是指为了使机体保持一段时间的体液负平衡,在限制液体输入量,增加液体排出量[2]。多项研究显RFMS能明显改善急性肺损伤(ALI)、感染、ARDS、休克患者的肺功能及预后[3][4][5],但在烧伤领域未见相关研究。就此我们推测对处回吸收期大面积烧伤患者行RFMS,可减轻容负担,降低肺水含量,改善肺脏氧合功能,减少肺脏并发症以及改善预后。本研究拟通过对回吸收期大面积烧伤患者采用RFMS和常规液体管理,在PICCO监测的基础上等明确RFMS在调节大面积烧伤患者早期体液平衡,控制肺水异常及防治肺脏并发症方面的作用,为大面积烧伤患者早期精准监测、防治肺水肿提供依据。对象与方法采取非随机的前瞻性研究方法,通过了西南医院伦理审查委员会的审批,患者均签署知情同意书。对照组收集2012年6月-2014年12月入住西南医院烧伤科的32例大面积烧伤患者,限制组收集2015年1月-2016年7月入住西南医院烧伤科的29例大面积烧伤患者。两组休克期(伤后2天)治疗方法相同,回吸收期对照组常规治疗,限制组实施RFMS,即适当控制补液总量+通过利尿促进体液排出(定时定量静推速尿,5mg/次,4-6次/日,总量20-30mg/日)。采用PICCO监测仪连续监测两组患者回吸收期血流动力学指标(ELWI、肺血管通透性指数PVPI、每搏输出量指数SVI、心脏指数CI、左心室收缩力指数dpmx、平均动脉压MAP、全心舒张末期容积指数GEDI、胸腔内血容积指数ITBI、全身外周血管阻力指数SVRI);经管护士记录两组患者每日液体出入量,并计算出每日液体净平衡和每日累积液体净平衡;记录两组患者每日常规生化检查、细菌培养结果。记录两组患者回吸收期使用呼吸机的情况,伤后2周内ARDS、肺部感染和血液感染的发生率,2周内其他脏器并发症的发生情况以及伤后4周内病情恶化及死亡的例数。SPSS22.0行统计分析,连续性数据采用均数±标准差,计量资料采用独立样本t检验、重复测量,计数资料采用χ2检验等统计方法;检验水准α=0.05。结果1.人口统计学资料介绍两组患者在年龄、性别、身高、体重、入院时间差、烧伤原因分类、吸入性损伤及创面大小等方面进行比较,均无统计学差异(P0.05),具有可比性。2.回吸收期RFMS对液体平衡的影响回吸收期两组患者每日液体净平衡呈下降趋势,限制组各时间点均低于对照组,且第6天差异有统计学意义(P0.05);回吸收期两组患者回每日累积液体净平衡呈上升趋势,而限制组始终低于对照组,且各时间点P值均小于0.05;回吸收期限制组蛋白略高于对照组,血钾(K)、血钠(Na)等电解质浓度两组均处于正常水平范围。3.回吸收期RFMS对血流动力学的影响进入回吸收期后,两组患者GEDI和ITBI都逐步上升,于伤后第7天达高峰;之后限制组GEDI和ITBI呈下降趋势,至伤后第10天达正常范围下限,而对照组GEDI和ITBI在伤后第7-10天呈持续高水平状态,接近或略超正常值上限。两组GEDI在伤后第4、10天差异有统计学意义,ITBI在伤后第10天有差异有统计学意义(P0.05)。回吸收期两组患者CI都逐步上升,第4-10天均高于正常上限,均在第6天达峰值,随后略逐渐下降,限制组降幅更明显。回吸收期两组患者MAP和SVI均在正常范围,二者比较无统计学差异。限制组心肌收缩指标dpmx于伤后第4-10天略高于对照组;限制组SVRI从休克期末至伤后第7天略高于对照组。4.回吸收期RFMS对两组患者ELWI和OI的影响回吸收期对照组ELWI均高于正常值上限,限制组仅在伤后7-9天高于正常值上限,且回吸收期对照组均高于限制组,第4天组间差异有统计学意义(P0.05)。回吸收期两组患者出现ELWI异常的总天数分别为:限制组82天,对照组134天;ELWI异常天数的比例分别为35.3%和52.3%,二者比较具有统计学差异(P0.01)。两组患者回吸收期OI均表现出下降趋势,以对照组降幅更为明显,限制组伤后第3-8天高于对照组。5.回吸收期RFMS呼吸机使用和肺脏并发症的影响回吸收期呼吸机使用情况为对照组15例,限制组6例,二者具有显著差异(P=0.030.05)。对照组呼吸机使用总天数为105天,占回吸收期总天数的41.02%,人均3.28天;限制组呼吸机使用总天数43天,占回吸收期总天数的18.53%,人均1.48天,二者比较具有显著差异(P=0.000.01)。伤后2周内限制组4例发生ARDS,对照组12例;限制组5例发生肺部感染,对照组14例;二者比较均有统计学差异(P0.05)。6.回吸收期RFMS对血液感染、其他脏器并发症与死亡情况的影响伤后2周内,血液感染发生情况为限制组6例,对照组18例,组间比较P值小于0.05。伤后2周内,限制组6例发生其他4种脏器并发症,对照组15例发生其他8种脏器并发症,P值小于0.05,差异有统计学意义。伤后4周内,限制组1例死亡,9例病情恶化,对照组7例死亡,15例病情恶化,二者比较P值均小于0.05,差异均有统计学意义。结论1.回吸收期RFMS可有效减少大面积烧伤每日液体净平和累计液体净平衡,一定程度提高血浆蛋白含量,对电解质浓度未见明显影响。2.回吸收期RFMS可有效控制大面积烧伤容量增加,一定程度提升心脏功能,对其他血流动力学指标未见不良影响。3.回吸收期RFMS可有效预防大面积烧伤患者ELWI异常升高,一定程度改善肺氧合功能,减少呼吸机使用,降低肺部感染和ARDS等肺脏并发症。4.回吸收期RFMS可减少大面积烧伤早期其他脏器并发症和血流感染的发生,减少病情恶化,降低死亡率,对改善大面积烧伤预后具有积极意义。
[Abstract]:Background and objective large area burns patients have many complications, and the incidence of lung complications is the highest. Pulmonary edema is easy to occur in the early stage of large area burns, pulmonary edema is pulmonary infection, acute respiratory distress syndrome (ARDS) or respiratory dysfunction can cause multiple organ function in patients with large area burns. Failure (MODS) or even death has an important influence on the prognosis and prognosis of patients with large area burns. The traditional pulmonary water monitoring method can not accurately measure the content of the extravascular lung water, and the operation is complex and the clinical practicability is not high. The monitoring and prevention of early pulmonary water in the patients with large area burns is limited. There is a positive correlation. The degree of pulmonary edema can be quantified by pulse indicator continuous cardiac output (PICCO) capacity monitor by the content of the extravascular lung water (indicator continuous cardiac output, PICCO). The quantitative monitoring of the content of extravascular pulmonary water in patients with the bed side of the bed is the only new technique for the quantitative monitoring of the content of the lung water by the dynamic side of the bed. With PICCO continuous monitoring, patients with large area burns entered the reabsorption period (3-10 days after injury), and the extravascular pulmonary edema index (ELWI) showed a continuous increase, which was higher than the normal high value (7mL/kg). It showed that there were different degrees of pulmonary edema in the early stage of large area burn. The early lung function of area burns was negatively correlated with ELWI. The above study revealed the early changes in the lung water and its possible clinical significance. The restrictive liquid management strategy (restrictive fluid management strategy, RFMS) means to keep the body fluid negative balance for a period of time and limit the amount of liquid input, A number of [2]. studies show that RFMS can obviously improve the lung function and prognosis of acute lung injury (ALI), infection, ARDS, shock, and [3][4][5], but there is no related research in the field of burn. Therefore, we speculate that RFMS can reduce the burden, reduce the content of lung water and improve the oxygenation function of the patients with large area burns at the reabsorption period. To reduce the lung complications and improve the prognosis. The purpose of this study is to use RFMS and conventional liquid management for patients with large area burns in the reabsorption period, to clarify the role of RFMS in regulating early body fluid balance in patients with large area burns, control of abnormal pulmonary water and prevention of pulmonary complications by PICCO monitoring. Early precision monitoring provides the basis for the prevention and treatment of pulmonary edema. The object and method adopted a non random prospective study method, through the examination and approval of the Southwest Hospital ethics review committee, the patients signed the informed consent. The control group collected 32 cases of large area burn patients admitted to the Department of burns in December, June 2012 -2014, and the restriction group collected 201 29 cases of large area burn patients in Southwest Hospital, Southwest Hospital in January -2016 years, 5 years. The two groups of shock period (2 days after injury) were treated in the same way. The control group was treated with the same routine treatment, the control group was treated with RFMS, that is, proper control of the total amount of rehydration and promoting the discharge of body fluid through diuresis (timing quantitative static push urine, 5mg/ times, 4-6 times, total 20-30mg/ days). The hemodynamic indexes of two groups of patients were continuously monitored by PICCO monitor (ELWI, pulmonary vascular permeability index PVPI, per stroke output index SVI, cardiac index CI, left ventricular contractile force index dpmx, mean arterial pressure MAP, total cardiac end diastolic volume index GEDI, thoracic cavity blood volume index ITBI, peripheral vascular resistance index SVRI). The nurses recorded the daily liquid entry and exit of two groups of patients and calculated the daily net balance of liquid and the daily accumulated liquid balance. Record the daily routine biochemical tests and the results of bacterial culture in two groups of patients. Records of the use of ventilator during the reabsorption period of the two groups, the incidence of ARDS, pulmonary infection and blood infection within 2 weeks after the injury, within 2 weeks. The occurrence of other visceral complications and the number of cases of disease worsening and death within 4 weeks after injury were analyzed by.SPSS22.0. The continuous data adopted mean standard deviation of mean number, independent sample t test, repeated measurement, and count data using chi 2 test and other statistical methods, and 1. demographic data of test level alpha =0.05. results were introduced. Two groups of patients were compared in age, sex, height, weight, time of admission, classification of causes of burn, inhalation injury and size of wound. There was no statistical difference (P0.05). There was a comparability of the effect of.2. reabsorption period RFMS on liquid balance in the reabsorption period of two groups. The difference between the sixth days was statistically significant (P0.05), and the daily accumulated liquid net balance of the two groups was higher than that of the control group, and the P value at each time point was less than 0.05, and the reabsorption limit group protein was slightly higher than the control group, and the serum potassium (K), and the blood sodium (Na) and other electrolyte concentrations were all in the group. After the effect of RFMS on hemodynamics in the normal level of.3. absorption period into the reabsorption period, the two groups of patients with GEDI and ITBI increased gradually, and at the peak of seventh Tianda after injury; after that, the GEDI and ITBI in the restricted group declined, to the lower limit of the normal range of tenth Tianda after injury, while the control group GEDI and ITBI were in a continuous high level after the injury on the 7-10 day after injury. The difference between two groups of GEDI was statistically significant at 4,10 days after injury. The difference between ITBI and tenth days after injury was statistically significant (P0.05). CI in two groups of patients in the reabsorption period were gradually higher than the normal upper limit, all at the peak of sixth in Tianda. The two groups of patients with MAP and SVI were in the normal range, and there was no statistical difference between the two. The myocardial contraction index of the restricted group was slightly higher than the control group on day 4-10 after injury, and the limit group SVRI was slightly higher than the control group at the end of the injury after the injury to the control group at the.4. reabsorption period of RFMS to the two groups of ELWI and OI in the reabsorption period of the control group, which were all higher than the normal values. The limit group was higher than the upper limit of normal value only 7-9 days after injury, and the control group in the reabsorption period was higher than the limit group, and the difference between the fourth days was statistically significant (P0.05). The total days of the abnormal ELWI in the two groups were 82 days in the restriction group and 134 days in the control group; the proportion of the abnormal days of the ELWI was 35.3% and 52.3% respectively, and the two comparison was compared. There was a statistical difference (P0.01). In the two groups, the OI showed a downward trend in the reabsorption period, and the decrease was more obvious in the control group. The 3-8 day after the injury in the control group was higher than that of the control group, the use of RFMS ventilator and the lung complications in the.5. reabsorption period of the control group were 15 cases in the control group and 6 in the restricted group, and the two of the two groups had a significant difference. P=0.030.05. The total days of the control group were 105 days, 41.02% of the total days in the reabsorption period, 3.28 days per person, 43 days for the total days of the ventilator in the restricted group, 18.53% of the total days in the reabsorption period, 1.48 days per person, and two (P=0.000.01). In the 2 weeks after injury, 4 cases were ARDS, 12 cases in the control group and 5 in the restriction group. There were 14 cases of pulmonary infection and 14 cases in the control group, and there were statistically significant differences (P0.05) in the.6. reabsorption period, the effect of RFMS on blood infection, other organ complications and death in 2 weeks after injury, the incidence of blood infection was 6 cases in the restricted group and 18 in the control group. The P value was less than 2 weeks after the 0.05. injury, and 6 other 4 species occurred in the restricted group. 15 cases of other 8 organ complications in the control group, the P value was less than 0.05, the difference was statistically significant. Within 4 weeks after the injury, 1 cases were dead, 9 cases were deteriorated, 7 cases in the control group died, 15 cases deteriorated, and the two were all less than 0.05 in the P value, and the difference had the significance of overall planning. Conclusion the RFMS in the 1. absorption period could effectively reduce the large area. The daily net balance of the liquid and the accumulated liquid balance can improve the plasma protein content to a certain extent. There is no obvious effect on the electrolyte concentration in the.2. absorption period. RFMS can effectively control the increase of large area burn capacity, improve the cardiac function to a certain extent, and have no adverse effect on the other hemodynamic indexes in the.3. recovery period, RFMS can be effectively prevented. The abnormal increase of ELWI in patients with large area burns, a certain degree of improvement of pulmonary oxygenation, reducing the use of ventilator, reducing pulmonary infection and ARDS and other lung complications in.4. recovery period RFMS can reduce the occurrence of other organ complications and blood flow infection in the early stage of large area burns, reduce the disease and reduce the mortality, and improve the prognosis of large area burns. It is of positive significance.
【学位授予单位】：第三军医大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R473.6
本文编号：2124774
[Abstract]:Background and objective large area burns patients have many complications, and the incidence of lung complications is the highest. Pulmonary edema is easy to occur in the early stage of large area burns, pulmonary edema is pulmonary infection, acute respiratory distress syndrome (ARDS) or respiratory dysfunction can cause multiple organ function in patients with large area burns. Failure (MODS) or even death has an important influence on the prognosis and prognosis of patients with large area burns. The traditional pulmonary water monitoring method can not accurately measure the content of the extravascular lung water, and the operation is complex and the clinical practicability is not high. The monitoring and prevention of early pulmonary water in the patients with large area burns is limited. There is a positive correlation. The degree of pulmonary edema can be quantified by pulse indicator continuous cardiac output (PICCO) capacity monitor by the content of the extravascular lung water (indicator continuous cardiac output, PICCO). The quantitative monitoring of the content of extravascular pulmonary water in patients with the bed side of the bed is the only new technique for the quantitative monitoring of the content of the lung water by the dynamic side of the bed. With PICCO continuous monitoring, patients with large area burns entered the reabsorption period (3-10 days after injury), and the extravascular pulmonary edema index (ELWI) showed a continuous increase, which was higher than the normal high value (7mL/kg). It showed that there were different degrees of pulmonary edema in the early stage of large area burn. The early lung function of area burns was negatively correlated with ELWI. The above study revealed the early changes in the lung water and its possible clinical significance. The restrictive liquid management strategy (restrictive fluid management strategy, RFMS) means to keep the body fluid negative balance for a period of time and limit the amount of liquid input, A number of [2]. studies show that RFMS can obviously improve the lung function and prognosis of acute lung injury (ALI), infection, ARDS, shock, and [3][4][5], but there is no related research in the field of burn. Therefore, we speculate that RFMS can reduce the burden, reduce the content of lung water and improve the oxygenation function of the patients with large area burns at the reabsorption period. To reduce the lung complications and improve the prognosis. The purpose of this study is to use RFMS and conventional liquid management for patients with large area burns in the reabsorption period, to clarify the role of RFMS in regulating early body fluid balance in patients with large area burns, control of abnormal pulmonary water and prevention of pulmonary complications by PICCO monitoring. Early precision monitoring provides the basis for the prevention and treatment of pulmonary edema. The object and method adopted a non random prospective study method, through the examination and approval of the Southwest Hospital ethics review committee, the patients signed the informed consent. The control group collected 32 cases of large area burn patients admitted to the Department of burns in December, June 2012 -2014, and the restriction group collected 201 29 cases of large area burn patients in Southwest Hospital, Southwest Hospital in January -2016 years, 5 years. The two groups of shock period (2 days after injury) were treated in the same way. The control group was treated with the same routine treatment, the control group was treated with RFMS, that is, proper control of the total amount of rehydration and promoting the discharge of body fluid through diuresis (timing quantitative static push urine, 5mg/ times, 4-6 times, total 20-30mg/ days). The hemodynamic indexes of two groups of patients were continuously monitored by PICCO monitor (ELWI, pulmonary vascular permeability index PVPI, per stroke output index SVI, cardiac index CI, left ventricular contractile force index dpmx, mean arterial pressure MAP, total cardiac end diastolic volume index GEDI, thoracic cavity blood volume index ITBI, peripheral vascular resistance index SVRI). The nurses recorded the daily liquid entry and exit of two groups of patients and calculated the daily net balance of liquid and the daily accumulated liquid balance. Record the daily routine biochemical tests and the results of bacterial culture in two groups of patients. Records of the use of ventilator during the reabsorption period of the two groups, the incidence of ARDS, pulmonary infection and blood infection within 2 weeks after the injury, within 2 weeks. The occurrence of other visceral complications and the number of cases of disease worsening and death within 4 weeks after injury were analyzed by.SPSS22.0. The continuous data adopted mean standard deviation of mean number, independent sample t test, repeated measurement, and count data using chi 2 test and other statistical methods, and 1. demographic data of test level alpha =0.05. results were introduced. Two groups of patients were compared in age, sex, height, weight, time of admission, classification of causes of burn, inhalation injury and size of wound. There was no statistical difference (P0.05). There was a comparability of the effect of.2. reabsorption period RFMS on liquid balance in the reabsorption period of two groups. The difference between the sixth days was statistically significant (P0.05), and the daily accumulated liquid net balance of the two groups was higher than that of the control group, and the P value at each time point was less than 0.05, and the reabsorption limit group protein was slightly higher than the control group, and the serum potassium (K), and the blood sodium (Na) and other electrolyte concentrations were all in the group. After the effect of RFMS on hemodynamics in the normal level of.3. absorption period into the reabsorption period, the two groups of patients with GEDI and ITBI increased gradually, and at the peak of seventh Tianda after injury; after that, the GEDI and ITBI in the restricted group declined, to the lower limit of the normal range of tenth Tianda after injury, while the control group GEDI and ITBI were in a continuous high level after the injury on the 7-10 day after injury. The difference between two groups of GEDI was statistically significant at 4,10 days after injury. The difference between ITBI and tenth days after injury was statistically significant (P0.05). CI in two groups of patients in the reabsorption period were gradually higher than the normal upper limit, all at the peak of sixth in Tianda. The two groups of patients with MAP and SVI were in the normal range, and there was no statistical difference between the two. The myocardial contraction index of the restricted group was slightly higher than the control group on day 4-10 after injury, and the limit group SVRI was slightly higher than the control group at the end of the injury after the injury to the control group at the.4. reabsorption period of RFMS to the two groups of ELWI and OI in the reabsorption period of the control group, which were all higher than the normal values. The limit group was higher than the upper limit of normal value only 7-9 days after injury, and the control group in the reabsorption period was higher than the limit group, and the difference between the fourth days was statistically significant (P0.05). The total days of the abnormal ELWI in the two groups were 82 days in the restriction group and 134 days in the control group; the proportion of the abnormal days of the ELWI was 35.3% and 52.3% respectively, and the two comparison was compared. There was a statistical difference (P0.01). In the two groups, the OI showed a downward trend in the reabsorption period, and the decrease was more obvious in the control group. The 3-8 day after the injury in the control group was higher than that of the control group, the use of RFMS ventilator and the lung complications in the.5. reabsorption period of the control group were 15 cases in the control group and 6 in the restricted group, and the two of the two groups had a significant difference. P=0.030.05. The total days of the control group were 105 days, 41.02% of the total days in the reabsorption period, 3.28 days per person, 43 days for the total days of the ventilator in the restricted group, 18.53% of the total days in the reabsorption period, 1.48 days per person, and two (P=0.000.01). In the 2 weeks after injury, 4 cases were ARDS, 12 cases in the control group and 5 in the restriction group. There were 14 cases of pulmonary infection and 14 cases in the control group, and there were statistically significant differences (P0.05) in the.6. reabsorption period, the effect of RFMS on blood infection, other organ complications and death in 2 weeks after injury, the incidence of blood infection was 6 cases in the restricted group and 18 in the control group. The P value was less than 2 weeks after the 0.05. injury, and 6 other 4 species occurred in the restricted group. 15 cases of other 8 organ complications in the control group, the P value was less than 0.05, the difference was statistically significant. Within 4 weeks after the injury, 1 cases were dead, 9 cases were deteriorated, 7 cases in the control group died, 15 cases deteriorated, and the two were all less than 0.05 in the P value, and the difference had the significance of overall planning. Conclusion the RFMS in the 1. absorption period could effectively reduce the large area. The daily net balance of the liquid and the accumulated liquid balance can improve the plasma protein content to a certain extent. There is no obvious effect on the electrolyte concentration in the.2. absorption period. RFMS can effectively control the increase of large area burn capacity, improve the cardiac function to a certain extent, and have no adverse effect on the other hemodynamic indexes in the.3. recovery period, RFMS can be effectively prevented. The abnormal increase of ELWI in patients with large area burns, a certain degree of improvement of pulmonary oxygenation, reducing the use of ventilator, reducing pulmonary infection and ARDS and other lung complications in.4. recovery period RFMS can reduce the occurrence of other organ complications and blood flow infection in the early stage of large area burns, reduce the disease and reduce the mortality, and improve the prognosis of large area burns. It is of positive significance.
【学位授予单位】：第三军医大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R473.6
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