限制性液体管理策略防治严重烧伤早期肺脏并发症的临床研究

A restrictive fluid management strategy for prevention of pulmonary complications early after severe burns:a report of 29 cases

目的探讨限制性液体管理策略(restrictive fluid management strategy,RFMS)对严重烧伤早期肺脏并发症的防治作用。方法收集2012年6月至2014年12月入住西南医院烧伤科的严重烧伤患者32例作为对照组,收集2015年1月至2016年7月入住西南医院烧伤科的严重烧伤患者29例作为限制组。采用非随机前瞻性观察研究法分析:两组休克期(伤后2 d内)治疗方法相同,回吸收期(伤后3~10 d)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。采用脉搏轮廓持续心输出量(pulseindicator continuous cardiac output,Pi CCO)容量监护仪监测并记录两组患者伤后10 d内血流动力学指标;记录伤后10 d每日液体入/出量并计算液体净平衡;记录实验室生化检查、病原菌培养结果;统计回吸收期呼吸机使用情况;分析患者伤后2周内急性呼吸窘迫综合征(acute respiratory distress syndrome,ARDS)、肺部感染发生率。结果限制组回吸收期每日液体净平衡和每日累积液体净平衡均低于对照组。限制组回吸收期全心舒张末期容积指数(global end-diastolic volume index,GEDI)在各时间点上均低于对照组,对照组在伤后7d达正常值上限且持续在高水平维持,限制组于伤后7 d达峰值,此后呈下降趋势。对照组回吸收期血管外肺水指数(external venous lung water index,ELWI)均高于正常值上限,限制组仅在伤后7~9 d高于正常值上限。对照组和限制组回吸收期出现ELWI异常总天数的百分比分别为52.34%和35.34%,二者比较差异具有统计学意义(P<0.01)。回吸收期对照组15例使用呼吸机,限制组6例,差异具有统计学意义(P<0.05)。回吸收期呼吸机使用总天数的百分比分别为对照组41.02%,限制组18.53%,二者差异有统计学意义(P<0.01)。两组患者伤后2周内对照组12例发生ARDS,限制组4例;对照组14例发生肺部感染,限制组5例;二者比较差异均有统计学意义(P<0.05)。两组患者回吸收期心脏指数(CI)均高于正常值上限,平均动脉压(MAP)处于正常值范围。结论适当的RFMS可有效减少严重烧伤回吸收期液体净平衡,促进体液回吸收和减轻容量负荷,对预防和减轻早期严重烧伤肺水肿与肺部并发症具有重要作用。

Objective To analyze the effect of a restrictive fluid management strategy （RFMS） for prevention pulmonary complications in patients during the early stages following severe burns. Methods With 32 patients suffering from severe burns admitted in Southwest Hospital between June 2012 and December 2014 as the control group, 29 patients admitted between January 2015 and July 2016 were enrolled as the treatment group. Following identical treatment protocols within the initial 2 days, the control group and the treatment group received routine fluid therapy and RFMS-based treatment in 3~10 d postburn, respectively. Within 10 d postburn, the hemodynamic indexes of the 2 groups were monitored, and the fluid intake and output, daily fluid net balance, daily fluid cumulative net balance, results of laboratory test, pathogenic bacteria culture results and the use of ventilation were recorded. The incidences of acute respiratory distress syndrome （ARDS） and pulmonary infection within 2 weeks postburn were compared between the 2 groups. Results Both the daily fluid net balance and daily fluid cumulative net balance were lower in the treatment group than in the control group from 2 to 10 d postburn. The global end-diastolic volume index （GEDI） remained lower in the treatment group than in the control group from 2 to 10 d postburn, reaching the peak level on day 7 and still maintaining a high level afterwards in the control group; global end-diastolic uolume index（GEDI） peaked on day 7 in the treatment group and tended to decrease over time. The extravascular lung water index （ELWI） was above the normal level only from 7 to 9 d postburn in the treatment group, as compared with in 3 to 10 d in the control group; the percentage of the total days with abnormal ELWI since postburn day 2 was significantly greater in the control group （52.34% vs 35.34%, P〈0.01）. Six patients in the treatment group and 15 in the control group required assisted ventilation from 3 to 10 d postburn （P〈0.05）, with the percentages of total days with ventilation of 41.02% and 18.53% in the 2 groups, respectively （P〈0.01）. Lung infection and ARDS occurred within 2 weeks postburn in 14 and 12 patients in the control group, and in 5 and 4 patients in treatment group, respectively （P〈0.05）. In both the 2 groups, the cardiac index remained higher than normal but the mean arterial pressure was within the normal range from 3 to 10 d postburn. Conclusion Appropriate RFMS can effectively reduce fluid net balance in the fluid reabsorption stage following burn injury to promote body fluid resorption and reduce the load capacity, and thus is critical for preventing and ameliorating early pulmonary edema and pulmonary complications following severe burn injuries.