重度未控制性失血性休克三种复苏策略的比较

Comparison of three different resuscitation strategies on severe uncontrolled hemorrhagic shock in dogs

目的：比较重度未控制性失血性休克（UHS）早期延迟复苏、低压液体复苏和垂体后叶素复苏的效果。方法犬24只，采用股动脉穿刺放血使平均动脉压降至50 mm Hg，随机分为三组（n=8）：延迟复苏组（A组）不采用任何复苏措施，低压液体复苏组（B组）静脉输注羟乙基淀粉（HES200/0.5）、垂体后叶素组（C组）每次静注垂体后叶素0.1～0.4 U/kg，使MAP≥50 mm Hg，1 h后全部停止放血行充分容量复苏。监测放血前即刻（T0）、达到目标血压时（T1）、实施三种复苏方法后1 h（T2）、复苏平稳后2 h（T3）各时点的血流动力学指标及动脉血气参数，同时采血样本检测TNF-α和IL-10。观察实验犬出血量、存活率并取死亡或存活超过72 h立即处死后的心肌、肺、肾组织进行病理学检查。结果（1）血流动力学指标：在T2时点，A组的SBP、DBP、MAP、CVP、HR明显低于B组和C组（P〈0.05），且大多数动物（6/8）死亡。（2）炎症介质及动脉血气参数：T1和 T2时点，三组的碱缺失（BD）、血乳酸（BL）和 SvO2均与T0有明显差别（P〈0.01）；在T3时点，三组的BD和BL仍处在T1和T2之间，但SvO2恢复正常。三组TNF-α和IL-10的变化规律与BD和BL一致，但在T2和T3时点，A组与B、C两组之间有统计学差异（P〈0.05）。（3）出血量及成活率：在未控制性失血期，A组的失血量少于B和C组，但仅与B组有统计学差异（P〈0.05）。A组72 h的成活率为25%，明显低于B组的87.5%和C组的100%（P〈0.01）。（4）病理学检查：A组心、肺、肾病理损害程度都明显重于B、C两组，但C组的损害程度略轻于B组。结论在重度UHS条件下，垂体后叶素和低压液体复苏均为早期有效的复苏方式，两者复苏后的存活率均高且无统计学差异；但低压复苏组的失血和组织损伤程度比垂体后叶素组明显，复苏质量不如后者。延迟复苏不适宜用于重度UHS。

Objective To compare the effects of delayed resuscitation, hypotensive fluid resuscitation and pituitrin resuscitation on severe uncontrolled hemorrhagic shock（UHS） in dogs at early stage. Methods Severe UHS was produced by exsanguinating hemorrhage from femoral artery in 24 healthy dogs which were randomized into 3 groups（n=8）according to resuscitation strategies after MAP about 50 mm Hg. None resuscitation measure was given in group A（delayed resuscitation）, a small quantity of hydroxyethyl starch （HES200/0.5） and pituitrin （0.1-0.4 U/kg） was given via vein in group B and group C respectively to maintain goal blood pressure（50 mm Hg）. After 1 h, exsanguination was stopped and full volume resuscitation was given. Hemodynamics index, blood gas analysis, TNF-αand IL-10 were monitored at T0（before exsanguinating）, T1（the time for the goal blood pressure achieved）, T2（1 h after T1） and T3（2 h after T2）. Blood loss and survival to 72 hours were observed. The samples of heart, kidney and lung were taken for pathology test when the dogs died or were killed immediately after 72 h. Results （1）Hemodynamics：Compared with group B and group C, the SBP, DBP, MAP, CVP and HR of group A were significantly lower at T2（P〈0.05）, and most of the dogs（6/8） died. （2） Inflammatory medium and blood gas analysis：The BD, BL and SvO2 of the three groups were significantly difference from T0 at T1 and T2（P〈0.01）, but the SvO2 was normal at T3 in spite of the BD and BL were still high. The changes of TNF-αand IL-10 were the same as the BD and BL, but which of group A was significantly difference from group B and group C at T2 and T3（P〈0.05）. （3） Blood loss and survival rate：During uncontrolled blood loss, blood loss in group A was lower than that of group B（P〈0.05）, but here was no significant difference between group A and group C. The survival rates of 72 h in group A（25%） was significantly lower than that of group B（87.5%） and group C（100%）（P〈0.01）. （4）Pathology test： The pathological lesions of heart, kidney and lung in group A were more serious than that of group B and group C, but the lesion of group C was lighter than that of group B. Conclusion On severe uncontrolled hemorrhagic shock, both hypotensive fluid resuscitation and pituitrin resuscitation are effective at early stage, but the blood loss and organizational lesion of hypotensive fluid resuscitation are significantly more serious than that of pituitrin resuscitation, and delayed resuscitation is inadvisable.