不同晶胶比早期液体复苏对小儿重症急性胰腺炎患者血流动力学及预后的影响

Impact of fluid resuscitation with different crystalloid-colloid ratio on hemodynamics and prognosis in pediatric patients with severe acute pancreatitis

目的 比较不同比例的晶体液与胶体液（晶胶比）早期液体复苏对小儿重症急性胰腺炎（SAP）血流动力学及预后的影响.方法 48例SAP患儿急性期早期给予对症支持治疗,并给予早期液体复苏,以晶胶比3为界,将患儿按数字表法随机分为低晶胶比组和高晶胶比组,各24例.观察复苏前（T0）及复苏结束后即刻（T1）、24 h（T2）、48 h（T3）血流动力学指标的变化,记录两组患儿的补液量、并发症发生率及病死率.结果 两组患儿T1、T2、T3时点的中心静脉压（CVP）、心指数（CI）、血管外肺水指数（ELWI）及胸腔内血容量指数（ITBI）均较同组T0时点明显升高（P值均＜0.05）.除高晶胶比组的ELWI在T2时点较低晶胶比组明显升高外[（14.9±4.2）ml/m2比（11.9 ±3.1）ml/m2,P＜0.05）],其他时点两组血流动力学各指标的差异均无统计学意义.高晶胶比组24 h总补液量、晶体液量、第三间隙液体潴留量、晶胶比分别为（4931±518）、（3963±552）、（2619±367） ml及4.47±0.41,低晶胶比组分别为（4436±547）、（3348±421）、（1711±278） ml及2.31±0.37,高晶胶比组较低晶胶比组均显著升高（P值均＜0.05）,但高晶胶比组24 h胶体液量为（922±452） ml,显著低于低晶胶比组的（1117±390） ml（P＜0.05）.高晶胶比组机械通气率、心功能不全发生率、多器官功能衰竭发生率分别为58.3％、33.3％、25.0％,均显著高于低晶胶比组的25.0％、8.24％、4.12％（P值均＜0.05）,但两组病死率无显著差异.结论 小儿SAP采用低晶胶比液体进行限制性液体复苏,可有效改善血流动力学,减轻液体潴留,改善患儿预后.

Objective To investigate the impact of fluid resuscitation with different crystalloid-colloid ratios on hemodynamics and prognosis in pediatric patients with severe acute pancreatitis （SAP）. Methods Forty-eight patients with pediatric SAP were given supportive therapy and fluid resuscitation in the early acute phase. Patients were randomly divided into low crystalloid-colloid ratio group and high erystalloid-colloid ratio group according to erystalloid-colloid ratio （3：1 ） as the cutoff value, with 24 patients in each group. Hemodynamic parameters were observed at the time point of before fluid resuscitation （ T0）, and 0 （ T1 ） , 24 （T2） , 48 （ T3 ） hours after resuscitation, the quantity of fluid resuscitation, complications and mortality of the two groups were compared. Results Central venous pression（CVP） , Cardiac index （CI） , Extravascular lung water index （ELWI） ,Intrathoracic blood volume index （ITBI） at T1, T2, T3 were significantly higher than those at TO in both groups （ P 〈 0.05 ）. The ELWI of high crystalloid-colloid ratio group at T2 was significantly higher than that in low erystalloid-colloid ratio group [（ 14.9± 4.2）ml/m2 vs （11.9± 3.1）ml/m2, P 〈 0.05 ） ] , but the other hemodynamic parameters of both groups were not significantly different. The 24 h total volume of infused fluid, 24 h total volume of colloid, 24 h total amount of fluid retention in the third space, 24 h crystalloid-colloid ratio was （ 4931 ± 518 ）, （ 3963 ± 552 ）, （ 2619 ± 367 ） ml and 4.47 ± 0.41 in high crystalloid-eolloid ratio group, the corresponding values in low crystalloid-eolloid ratio group were （4436 ± 547） , （3348 ± 421 ） , （ 1711 ± 278 ） ml and 2.31 ± 0.37, the values in high crystalloid-colloid ratio group were significantly higher than those in low erystalloid-colloid ratio group （P 〈 0.05 ）. However, 24 h total volume of colloid in high crystalloid-colloid ratio group was significantly lower than that in low crystalloid-colloid ratio group [ （922 ± 452） ml vs （ 1117 ± 390） ml, P 〈 0.05 ]. The incidence of mechanical ventilation rate, cardiac insufficiency, MODS was 58.3%, 33.3%, 25.0% in high crystalloid-colloid ratio group, which were significantly higher than those in low crystalloid-colloid ratio group （25.0%, 8.24%, 4.2%, P 〈 0.05 ）, but the mortality was not significantly different. Conclusions A low crystalloid-colloid ratio should be considered for controlled fluid resuscitation in pediatric SAP patients in order to effectively improve hemodynamics, reduce fluid retention, and improve the prognosis.