严重烧伤延迟复苏后多器官功能障碍综合征的早期防治

Effect of improved resuscitation regime on the outcome of severely burned patients with delayed fluid resuscitation

目的 :评价改进休克复苏方案对严重烧伤患者延迟复苏后脓毒症和多器官功能障碍综合征 (MODS)防治效果。方法 :1992～ 1999年我科首诊收治的大面积烧伤延迟复苏 (伤后 6小时或 6小时后开始补液 )患者48例 ,对比分析采用改进休克复苏方案治疗与未采用改进方案治疗患者脓毒症和 MODS发生率和病死率。改进后的休克复苏方案为 :在 Swan Ganz导管监测下快速有效液体复苏的同时 ,使用山莨菪碱改善肠道血供 ;应用氧自由基清除剂维生素 C、维生素 E和甘露醇防治再灌注损伤。结果 :1992年以后 ,使用新方案治疗显著缩短了休克纠正时间 ,提高了复苏成功率。从观察结果来看 ,新方案可显著提高胃粘膜 p H值 ,降低血中丙二醛、二胺氧化酶和内毒素水平 ;从总的治疗效果来看 ,降低了患者脓毒症和 MODS发病率和病死率。结论 :改进的休克复苏方案提高了复苏效率 ,减轻了延迟复苏时缺血及再灌注造成的损害 ,进而有效降低了脓毒症和MODS发病率和病死率 。

Objective: To elucidate the effect of improved resuscitation measures on the morbidity and mortality of sepsis and multiple organ dysfunction syndrome(MODS).Methods:fortyeight extensively burned patients admitted to the department from Oct.1992 through Dec,1999 were included in this study.All these patients received delayed fluid resuscitation (fluid infusion began at or later than 6 hours postburn).Morbidity and mortality rates of sepsis and MODS were compared between two groups of patients with and without improved resuscitation measures.These measures were as follows:①prompt,rapid,and adequate fluid resuscitation under hemodynamic monitoring with SwanGanz catheter;②rapid restoration of bowel circulation by treatment with anisodamine;③prevention of further oxygen free radicals (OFR) injury to various tissues with OFR scavengers,including vitamin C,vitamin E,and mannitol.Results:With the application of the improved resuscitation measures,the morbidity rate of MODS was decreased from 45 5%(10/22) to 19 2%(5/26),and the mortality rate from 90 0%(9/10) to 60 0% (3/5).Meanwhile,the morbidity rate of sepsis was also significantly reduced (54 5% and 26 9%,respectively).Gastric intramucosal pH was significantly higher,but plasma MDA,diamine oxidase and endotoxin leves were markedly lower in patients treated with new measures than that without on postburn days 1,3 and 7.These results indicated that the new measures could effectively extenuate OFR injury,restore intestinal b arrier function and prevent endotoxin translocation from the gut,which might contribute to the favorable outcome.Conclusions:Improved resuscitation measures can effectively extenuate ischemic and reperfusion injury,decrease morbidity and mortality rates of patients with delayed fluid resuscitation after extensive bruns.