骨内输液在战创伤救治中应用的可行性研究

发布时间：2018-10-04 18:24

【摘要】： 20世纪20年代早期Drinker等人提出可利用骨髓腔血液循环通路输注液体。40年代至50年代骨内输液技术被广泛应用于急症救治,并证实血液、液体、药物均能经胸骨或胫骨骨髓快速、可靠地进入血液循环。Tocantins等人证实：刚果红染料注入兔胫骨，10秒后可到达中心血液循环。事实上，1990年的一系列文献报告：任何可经静脉输注的物质注入骨髓后几乎立即进入外周循环。在常规战争中，50%的阵亡伤员是由于大出血死亡，战伤伤口出血是造成伤后30%伤员死亡的主要原因。提高战地救治水平，减少伤死率便显得尤为重要。另一方面，在现代战争中，由于高技术武器的应用可能导致短时间在某一区域出现大批量伤员，且伤情严重、休克发生率高、大面积烧伤患者较多等，均导致建立静脉通道困难、置管耗时。寻找快速、有效、安全的静脉替代途径便显得尤为重要。美军陆军外科研究所单位在20世纪90年代重新开展了对骨内输液技术在成人救治中应用的评价。通过检索近30年国内文献以及专利检索证实，目前国内尚无开展骨内输液技术的报告。因此，为做好军事斗争的卫勤准备，应开展骨内输液技术的研究。本课题采用大白兔肢体火器伤致胫腓骨骨折模型模拟成人战伤。观察伤情特点及发展，经健肢胫骨骨内输液复苏效果，与静脉复苏对照研究骨内输液技术的有效性。并从三方面研究其安全性。第一方面：肢体火器伤后经健肢黄骨髓骨内输液后是否会产生肺动脉脂肪栓塞。并取输液部位胫骨作病理检查观察骨髓腔近期组织结构变化。第二方面：骨内输液是否对红骨髓造血微环境有影响。第三方面：骨内输液是否会造成骨髓感染以及远期骨髓腔组织结构变化。基于上述实验研究，临床成功应用骨内输液技术救治2例严重创伤休克患者。通过上述研究所得主要结果和结论如下：1 肢体火器伤后合并休克发生率高，肢体毁损重。2.胫骨穿刺输液成功准确率达95.8%,时间为84±22s;股静脉插管输液准确率也为95.8%，其时间为288±34s。3.四种临床常用的复苏液体与药物经胫骨骨内输液与经股静脉插管复苏效果对应一致。4. 肢体创伤后健肢骨内输液不会产生肺动脉脂肪栓塞叠加效应。5. 骨内输液对红骨髓造血微环境无明显影响。6. 骨内输液技术在一定时间内（24h）不会造成骨髓感染现象，，所以一旦容量复苏后应迅速建立静脉通道，维持时间最好不要超过24h。7.近远期骨内输液部位胫骨病理检查显示：近期无异常，远期有轻度纤维化。8.临床成功应用证实：骨内输液也是成人紧急情况下快速、可靠 WP=7 建立血管通道的最佳选择。
[Abstract]:In the early 1920s, Drinker et al proposed that the intraosseous infusion of fluid could be used through the circulation pathway of medullary cavity. From 1940s to 1950s, intraosseous infusion was widely used in emergency treatment, and proved that blood, fluid, and drugs could be transmitted quickly through sternum or tibial bone marrow. Reliable access to blood circulation. Tocantins et al. Confirmed that Congo red dye was injected into rabbit tibia and reached central blood circulation 10 seconds later. In fact, a series of literature published in 1990 reported that any substance that could be injected via vein into bone marrow entered the peripheral circulation almost immediately. In the conventional war, 50% of the casualties died as a result of massive bleeding, and the main cause of death was wound bleeding. It is particularly important to improve the level of field rescue and reduce the rate of injury and death. On the other hand, in modern warfare, because of the use of high-tech weapons, large numbers of casualties may appear in a certain area in a short period of time, and the injuries are serious, the incidence of shock is high, and there are more patients with extensive burns, etc. Both lead to the difficulty of establishing venous passage and the time consuming of catheterization. It is particularly important to find a fast, effective and safe alternative to the vein. The evaluation of intraosseous infusion technique in adult treatment was reconducted in the 1990s by the US Army Surgical Research Institute. Through the retrieval of domestic literature and patent retrieval in recent 30 years, there is no report on intraosseous infusion technology in China. Therefore, in order to prepare for military struggle, intraosseous infusion technique should be studied. The model of tibia and fibula fracture caused by firearm injury of limb of white rabbit was used to simulate adult war injury. The characteristics and development of the injury were observed, and the effect of intraosseous infusion resuscitation through tibia was studied, and the effectiveness of intraosseous infusion was compared with that of venous resuscitation. And from three aspects to study its safety. First, whether pulmonary artery fat embolism will occur after firearm injury through intraosseous infusion of yellow bone marrow. Tibia was taken from infusion site for pathological examination to observe the recent changes of tissue structure of medullary cavity. Second, whether intraosseous infusion has an effect on hematopoietic microenvironment of red bone marrow. Third, whether intraosseous infusion will cause bone marrow infection and long-term changes in bone marrow tissue structure. Based on the above experimental study, intraosseous infusion was successfully used to treat 2 patients with severe traumatic shock. The results and conclusions are as follows: (1) the incidence of shock after firearm injury is high, and the limb damage is heavy. 2. The accuracy rate of tibial puncture infusion was 95.8%, the time was 84 卤22s, and the accuracy rate of femoral vein infusion was 95.8s.The time was 288 卤34 s.3. Four common clinical resuscitation fluids and drugs received intraosseous infusion via tibia and femoral vein intubation respectively. There is no superposition effect of pulmonary artery fat embolism in healthy limb intraosseous infusion after limb trauma. Intraosseous infusion had no significant effect on hematopoietic microenvironment of red bone marrow. The intraosseous infusion technique will not cause bone marrow infection in a certain time (24 hours), so once volume resuscitation, vein passage should be established quickly, and the maintenance time should not exceed 24h.7. In the near and long term intraosseous infusion site tibia pathological examination showed that there was no abnormality in the near future and mild fibrosis in the long term. Clinical application has proved that intraosseous infusion is also rapid in adult emergencies. Reliable WP=7 is the best choice for establishing vascular passage.
【学位授予单位】：第三军医大学
【学位级别】：硕士
【学位授予年份】：2003
【分类号】：R826

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