脉搏轮廓心输出量监测技术指导特重度烧伤患者液体复苏对脏器功能的影响

Effect of fluid resuscitation guided by pulse contour cardiac output monitoring technology on organ function in extremely severe burn patients

目的探讨脉搏轮廓心输出量(PiCCO)监测技术指导特重度烧伤患者液体复苏对脏器功能的影响。方法选择2015年5月—2019年3月武汉大学同仁医院暨武汉市第三医院收治的符合入选标准的52例特重度烧伤患者,进行前瞻性随机对照研究。采用随机数字表法,将患者分为PiCCO监测补液组25例(男17例、女8例)和传统补液组27例(男20例、女7例),其年龄分别为(47±9)、(49±8)岁,患者入院后均按照第三军医大学休克期补液公式进行补液。传统补液组通过监测患者传统的休克指标尿量、中心静脉压等进行液体复苏;PiCCO监测补液组患者行PiCCO监测,在传统补液组监测指标的基础上,根据全心舒张末期容积指数并结合PiCCO监测的其他相关指标指导液体复苏。比较2组患者伤后第1、2个24 h补液系数、每小时每千克体质量尿量[同时与对应的第三军医大学休克期补液方案值(下称方案值)进行比较],伤后8 h内及第1、2个24 h补液总量,伤后第1、2个24 h每小时尿量,伤后1、2、3 d血液中肌酐、尿素氮、乳酸清除率、降钙素原、心肌型肌酸激酶同工酶(CK-MB)及平均动脉压(MAP)水平,伤后28 d内并发症发生情况、机械通气应用例数及机械通气时间。对数据行重复测量方差分析、t检验、Bonferroni校正、Mann-Whitney U检验、χ^2检验、Fisher确切概率法检验。结果伤后第2个24 h,传统补液组患者的补液系数较方案值明显升高(t=5.120,P<0.01)。伤后第1、2个24 h,PiCCO监测补液组患者补液系数明显高于方案值(t=3.655、10.894,P<0.01)和传统补液组(t=3.172、2.363,P<0.05或P<0.01)。伤后8 h内,2组患者补液总量相近。伤后第1、2个24 h,PiCCO监测补液组患者补液总量明显多于传统补液组(t=4.428、3.665,P<0.01)。伤后第1、2个24 h,与方案值比较,传统补液组患者每小时每千克体质量尿量均明显升高(t=4.293、6.362,P<0.01),PiCCO监测补液组患者每小时每千克体质量尿量均明显升高(t=6.461、8.234,P<0.01);伤后第2个24 h,PiCCO监测补液组患者每小时每千克体质量尿量和每小时尿量均明显高于传统补液组(t=2.849、3.644,P<0.05或P<0.01)。伤后1、2、3 d,2组患者肌酐水平相近。伤后1、2、3 d,PiCCO监测补液组患者尿素氮水平分别为(6.8±1.5)、(5.6±1.4)、(4.4±1.4)mmol/L,均明显低于传统补液组的(8.6±1.8)、(6.6±1.5)、(5.5±1.4)mmol/L(t=3.817、2.511、2.903,P<0.05或P<0.01)。伤后1、2、3 d,PiCCO监测补液组患者乳酸清除率明显高于传统补液组(t=2.516、4.540、3.130,P<0.05或P<0.01)。伤后2、3 d,PiCCO监测补液组患者降钙素原水平明显低于传统补液组(Z=-2.491、-2.903,P<0.05)。伤后3 d,PiCCO监测补液组患者CK-MB水平为(35±10)U/L,明显低于传统补液组的(51±16)U/L(t=4.556,P<0.01)。伤后1、2、3 d,2组患者MAP水平相近。伤后28 d内,传统补液组患者并发症发生率明显高于PiCCO监测补液组(χ^2=4.995,P<0.05),2组患者机械通气应用例数及通气时间相近。结论采用PiCCO监测技术指导特重度烧伤早期液体复苏有利于精准判断患者所需液体量,并能减轻因补液不当引起的脏器损伤。

Objective To investigate the effect of fluid resuscitation guided by pulse contour cardiac output(PiCCO)monitoring technology on the organ function in extremely severe burn patients.Methods From May 2015 to March 2019,52 patients with extremely severe burn hospitalized in Tongren Hospital of Wuhan University&Wuhan Third Hospital,meeting the inclusion criteria,were recruited to conduct a prospectively randomized control study.The patients were divided into PiCCO monitoring rehydration group(25 cases,17 males and 8 females)and traditional rehydration group(27 cases,20 males and 7 females)according to the random number table,with the ages of(47±9)and(49±8)years respectively.After admission,all the patients were rehydrated according to the rehydration formula of the Third Military Medical University during shock stage.In traditional rehydration group,fluid resuscitation of the patients was performed by monitoring the traditional shock indicators such as urine volume and central venous pressure,while PiCCO monitoring was performed in patients in PiCCO monitoring rehydration group,and the global end-diastolic volume index combined with the other relevant indicators of PiCCO monitoring were used to guide rehydration on the basis of the monitoring indicators of traditional rehydration group.The rehydration coefficients and urine volumes per kilogram of body weight per hour during the first and second 24 h post injury were compared between the two groups,which were compared with the corresponding rehydration scheme value of the Third Military Medical University(hereinafter referred to as the scheme value)at the same time.The total rehydration volumes within post injury hour(PIH)8 and during the first and second 24 h post injury,the urine volumes per hour during the first and second 24 h post injury,and the levels of creatinine,urea nitrogen,lactate clearance rate,procalcitonin,creatine kinase isoenzyme(CK-MB)in blood and mean arterial pressure(MAP)on post injury day(PID)1,2,and 3 were measured.The incidence of complications,the application case number of mechanical ventilation,and the mechanical ventilation time within PID 28 were analyzed.Data were statistically analyzed with analysis of variance for repeated measurement,t test,Bonferroni correction,Mann-Whitney U test,chi-square test,and Fisher′s exact probability method test.Results During the second 24 h post injury,the rehydration coefficient of patients in traditional rehydration group was significantly higher than the scheme value(t=5.120,P<0.01).During the first and second 24 h post injury,the rehydration coefficients of patients in PiCCO monitoring rehydration group were significantly higher than the scheme values(t=3.655,10.894,P<0.01)and those in traditional rehydration group(t=3.172,2.363,P<0.05 or P<0.01).Within PIH 8,the total rehydration volumes of patients between the two groups were similar.During the first and second 24 h post injury,the total rehydration volumes of patients in PiCCO monitoring rehydration group were significantly higher than those in traditional rehydration group(t=4.428,3.665,P<0.01).During the first and second 24 h post injury,the urine volumes per kilogram of body weight per hour of patients in traditional rehydration group were significantly higher than the schema values(t=4.293,6.362,P<0.01),and the urine volumes per kilogram body weight per hour of patients in PiCCO monitoring rehydration group were significantly higher than the schema values(t=6.461,8.234,P<0.01).The urine volumes per kilogram of body weight per hour and urine volumes per hour of patients in PiCCO monitoring rehydration group during the second 24 h post injury were significantly higher than those in traditional rehydration group(t=2.849,3.644,P<0.05 or P<0.01).The creatinine levels of patients between the two groups on PID 1,2,and 3 were similar.The urea nitrogen levels of patients in PiCCO monitoring rehydration group on PID 1,2,and 3 were(6.8±1.5),(5.6±1.4),(4.4±1.4)mmol/L respectively,which were significantly lower than(8.6±1.8),(6.6±1.5),(5.5±1.4)mmol/L in traditional rehydration group(t=3.817,2.511,2.903,P<0.05 or P<0.01).The lactate clearance rates of patients in PiCCO monitoring rehydration group on PID 1,2,and 3 were significantly higher than those in traditional rehydration group(t=2.516,4.540,3.130,P<0.05 or P<0.01).The procalcitonin levels of patients in PiCCO monitoring rehydration group on PID 2 and 3 were significantly lower than those in traditional rehydration group(Z=-2.491,-2.903,P<0.05).The CK-MB level of patients in PiCCO monitoring rehydration group on PID 3 was(35±10)U/L,which was significantly lower than(51±16)U/L in traditional rehydration group(t=4.556,P<0.01).The MAP levels of patients between the two groups on PID 1,2,and 3 were similar.Within PID 28,the incidence of complications of patients in traditional rehydration group was significantly higher than that in PiCCO monitoring rehydration group(χ^2=4.995,P<0.05),and the application case number of mechanical ventilation and the mechanical ventilation time of patients between the two groups were similar.Conclusions The use of PiCCO monitoring technology to guide the early fluid resuscitation of extremely severe burn patients is beneficial for accurate determination of the fluid volume required by the patients and reduction of organ injury caused by improper rehydration.