37℃扩容液对感染性休克新生儿凝血功能及血乳酸的影响

Effects of 37℃ volume resuscitation on coagulation function and blood lactic acid in neonates with septic shock

目的探讨主动干预扩容液至37℃抗休克治疗对新生儿凝血功能和微循环的影响。方法选择江西省赣南医学院第一附属医院新生儿重症加强治疗病房(NICU)收治的感染性休克患儿,采用随机数字表法将24例感染性休克新生儿分为两组(每组12例),分别在常规治疗基础上使用25℃生理盐水(NS)和37℃NS扩容,每次10mL/kg。分别于治疗前及治疗6h、12h检测凝血因子Ⅱ、Ⅴ、Ⅶ、Ⅷ、Ⅸ、Ⅹ以及凝血酶原时间(PT)、凝血酶时间(TT)、纤维蛋白原(FIB)、活化部分凝血活酶时间(APTT)、D-二聚体(DD)和乳酸(Lac)水平。结果不同温度扩容液两组休克患儿治疗前后各凝血因子Ⅱ、Ⅴ、Ⅶ、Ⅷ、Ⅸ、Ⅹ水平均无明显变化,且组间比较差异无统计学意义。两组休克患儿治疗后PT、ATPP均逐渐缩短,DD、Lac均逐渐下降,FIB均逐渐升高,而TT则无明显变化,其中37℃NS组治疗后6hPT、APTT、DD、Lac即显著低于治疗前[PT(s):14.07±1.02比17.08±1.54,APTT(s):54.83±12.39比69.17±16.36,DD(mg/L):2.40±0.63比4.18±0.88,Lac(mmol/L):2.84±0.82比5.98±1.17,均P<0.05];25℃NS组治疗后6hDD、Lac即显著低于治疗前[DD(mg/L):3.13±0.84比4.16±1.04,Lac(mmol/L):4.83±0.64比5.69±0.74,均P<0.05],治疗后12hPT才较治疗前明显缩短(s:14.63±1.14比16.48±1.61,P<0.01);25℃NS组和37℃NS组治疗后12hFIB均明显高于治疗前(g/L:2.83±0.83比1.58±0.43,2.87±0.87比1.47±0.41,均P<0.01),而TT均无明显变化。组间比较显示:治疗后6h,37℃组PT、DD、Lac显著低于25℃NS组[PT(s):14.07±1.02比15.69±1.21,DD(mg/L):2.40±0.63比3.13±0.84,Lac(mmol/L):2.84±0.82比4.83±0.64,均P<0.05];治疗后12h时,37℃NS组PT、APTT、DD均显著低于25℃NS组[PT(s):13.26±0.91比14.63±1.14,APTT(s):37.08±10.43比54.75±14.96,DD(mg/L):1.20±0.59比2.06±0.69,均P<0.01],FIB显著高于25℃NS组(g/L:2.87±0.87比2.83±0.83,P<0.05)。结论主动干预扩容液NS至37℃扩容治疗,能够改善感染性休克新生儿的凝血功能和微循环状态。

Objective To investigate the effect of volume resuscitation with normal saline(NS)at 37℃ on the coagulation function and microcirculation of neonates with septic shock.Methods Children with septic shock admitted to neonatal intensive care unit(NICU)of the First Affiliated Hospital of Gannan Medical University were enrolled.Twenty-four newborns with septic shock were divided into two groups by random number table method(12 in each group),and were resuscitated with 10 mL/kg at 25℃ NS and 37℃ NS respectively on the basis of routine treatment.FactorⅡ,Ⅴ,Ⅶ,Ⅷ,Ⅸ,Ⅹ,and prothrombin time(PT),thrombin Time(TT),fibrinogen(FIB),activated partial thromboplastin time(APTT),D-Dimer(DD),lactic acid(Lac)were detected before treatment and 6 hours and 12 hours after treatment.Results The levels of coagulation factors Ⅱ,Ⅴ,Ⅶ,Ⅷ,Ⅸ,Ⅹ were not significantly changed before and after treatment in the two groups,and there was no significant difference between the two groups.After treatment,PT and APTT in both groups were gradually shortened,DD and Lac were gradually decreased,FIB were gradually increased,while TT had no significant change.Among them,PT,APTT,DD and Lac at 6 hours after treatment in 37℃NS group were significantly lower than those before treatment [PT(s):14.07±1.02 vs.17.08±1.54,APTT(s):54.83±12.39 vs.69.17±16.36,DD(mg/L):2.40±0.63 vs.4.18±0.88,Lac(mmol/L):2.84±0.82 vs.5.98±1.17,all P<0.05];DD and Lac at 6 hours after treatment in 25℃ NS group were significantly lower than those before treatment [DD(mg/L):3.13±0.84 vs.4.16±1.04,Lac(mmol/L):4.83±0.64 vs.5.69±0.74,both P<0.05],and PT at 12 hours after treatment was significantly shorter than that before treatment(s:14.63±1.14 vs.16.48±1.61,P<0.01);FIB in both 25℃ NS group and 37℃ NS group at 12 hours after treatment were significantly higher than those before treatment(g/L:2.83±0.83 vs.1.58±0.43,2.87±0.87 vs.1.47±0.41,both P<0.01),but TT had no significant change.The comparison between groups showed that PT,DD and Lac in the 37℃ NS group were significantly lower than those in the 25℃ NS group at 6 hours after treatment [PT(s):14.07±1.02 vs.15.69±1.21,DD(mg/L):2.40±0.63 vs.3.13±0.84,Lac(mmol/L):2.84±0.82 vs.4.83±0.64,all P<0.05];at 12 hours after treatment,PT,APTT and DD in the 37℃ NS group were significantly lower than those in the 25℃ NS group [PT(s):13.26±0.91 vs.14.63±1.14,APTT(s):37.08±10.43 vs.54.75±14.96,DD(mg/L):1.20±0.59 vs.2.06±0.69,all P<0.01],and FIB was significantly higher than that in the 25 ℃ NS group(g/L:2.87±0.87 vs.2.83±0.83,P<0.05).Conclusion Volume resuscitation at 37℃ can improve the coagulation function and microcirculation of newborns with septic shock.