限制性液体复苏在颅脑损伤合并多发伤失血性休克中的应用

发布时间：2018-05-11 14:20

本文选题：失血性休克 + 多发伤　；参考：《天津医科大学》2017年硕士论文

【摘要】：目的:探讨中重度颅脑损伤合并多发伤失血性休克患者的最佳液体复苏策略。方法:回顾性分析我科于2007年1月至2015年1月治疗的128例颅脑损伤合并多发伤失血性休克患者,根据不同的液体复苏方式分为积极液体复苏组(A组)和限制液体复苏组(B组),限制液体复苏组又依据选择复苏液种类的不同,分为B1组(HES+LR)和B2组(HES+7.5%HS),补液的量化调控标准:严密监测血流动力学,限制液体复苏组将平均动脉压控制在70-80mmHg,中心静脉压控制在6-8cmH2O,维持48小时,积极液体复苏组输注LR和HES,比例2-3:1,迅速恢复血容量,血压控制在患者基础血压水平,中心静脉压控制在8-12cmH2O,余治疗两组基本相同。对三组间的GCS昏迷评分、休克指数、凝血功能、CT颅内出血进展率、ARDS、MODS发生率及伤后6个月GOS评分等进行对比研究。结果:三组对比休克指数在治疗前后都明显改善,比较无显著差异(P0.05)。三组间在颅内出血进展率、GCS评分、ARDS、MODS发生率上比较,存在显著差异(P0.05),其中A组出血进展人数16例、ARDS 15例、MODS 14例均多于B1、B2组,GCS评分为7.1±2.4则不如B1、B2组,B1、B2组在颅内出血进展率、ARDS、MODS发生率、GCS评分上比较则无显著性差异。在凝血功能指标比较上,限制液体复苏组(B组)亦优于积极液体复苏组(A组),而复苏液的选择上B1组(HES+LR)与B2组(HES+7.5%高渗盐水HS)则无显著性差异。24小时补液量上三组对比具有显著性差异,其中B1、B2组对比差异亦具有显著性(P0.05)。随访6个月时以GOS评分评价,限制液体复苏组好于积极液体复苏组。结论:对于中重度颅脑损伤合并多发伤失血性休克患者积极液体复苏及限制性液体复苏均能有效改善休克状态,但在凝血功能、颅内出血进展率、ARDS、MODS发生率及伤后6个月GOS评分方面,采用限制性液体复苏的方法对患者更有益处。而限制性液体复苏时采用7.5%HS能减少输注的液体量,也许可防止休克早期对机体内环境的不利影响。
[Abstract]:Objective: to investigate the optimal fluid resuscitation strategy in patients with moderate and severe craniocerebral injury complicated with multiple hemorrhagic shock. Methods: a retrospective analysis of 128 patients with multiple traumatic hemorrhagic shock after craniocerebral injury was performed from January 2007 to January 2015. According to different ways of fluid resuscitation, they were divided into active fluid resuscitation group (group A) and restricted fluid resuscitation group (group B). B _ 1 group (HES LRR) and B2 group (HES 7.5) were divided into two groups: hemodynamics was closely monitored, mean arterial pressure was controlled at 70-80 mm Hg in fluid resuscitation group, and central venous pressure was controlled at 6-8 cm H _ 2O for 48 hours. In the positive fluid resuscitation group, LR and HES were infused with a ratio of 2 to 3: 1, the blood volume recovered rapidly, the blood pressure was controlled at the basic blood pressure level of the patients, and the central venous pressure was controlled at 8-12 cm H _ 2O. The other two groups were basically the same. The scores of GCS coma, shock index, coagulation function and the progression rate of intracranial hemorrhage in CT were compared among the three groups. The incidence of ARDS mods and the GOS score at 6 months after injury were compared between the three groups. Results: the contrastive shock index of the three groups was significantly improved before and after treatment, and there was no significant difference between the three groups (P 0.05). The rate of progression of intracranial hemorrhage and the incidence of ARDS mods were compared among the three groups. There was a significant difference (P < 0.05). There was no significant difference in the rate of progression of intracranial hemorrhage and the incidence of ARDS mods and GCS score in group A (n = 16) and ARDS group (n = 15) and mods group (n = 14), which was higher than that in group B _ (1) or B _ (2) group with a GCS score of 7.1 卤2.4, which was not significantly different from that in group B _ (1) and B _ (1) B _ (2) group. On the comparison of coagulation function indexes, The resuscitation group was also superior to the positive fluid resuscitation group (group A), but the choice of resuscitation fluid was not significantly different between group B1 (HES LRR) and group B2 (7.5% hypertonic saline HS). There was no significant difference among the three groups in fluid resuscitation at 24 hours. The contrast difference of group B _ 1 and B _ 2 was also significant (P 0.05). At 6 months follow-up, the GOS score showed that the fluid resuscitation group was better than the positive fluid resuscitation group. Conclusion: both positive fluid resuscitation and restrictive fluid resuscitation can effectively improve the state of shock in patients with moderate and severe craniocerebral injury complicated with hemorrhagic shock of multiple injuries. In terms of the rate of progression of intracranial hemorrhage and the incidence of ARDS mods and the GOS score at 6 months after injury, restrictive fluid resuscitation was more beneficial to the patients. However, the use of 7.5%HS during restricted fluid resuscitation can reduce the volume of fluid infusion, and may prevent the adverse effects on the body's environment in the early stage of shock.
【学位授予单位】：天津医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R651.15

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