损伤控制复苏在多发骨折合并出血性休克救治中的临床观察

Clinical observation of damage control resuscitation in rescue multiple fracture with hemorrhagic shock

目的:探讨损伤控制性复苏(damage control resuscitation,DCR)在严重骨折合并创伤未控制的失血性休克救治中的临床疗效。方法:回顾性分析2009年1月至2013年5月收治的24例多发骨折合并出血未控制性休克患者的临床资料,其中男18例,女6例;年龄21~48岁,平均(32.5±4.5)岁。术前应用小容量平衡盐液维持收缩压(80~90)mmHg。手术控制出血后快速足量液体复苏,并按照血浆∶悬浮红细胞=1 U∶2 U^1 U∶1 U的比例给予血浆。休克纠正后,维持液体轻度负平衡及电解质酸碱平衡,记录休克纠正前的平衡盐液用量及输血量,动态观察乳酸清除时间、凝血功能、DIC发病率及病死率等指标,延期骨折确定性手术。结果:4例入院后6~18 h抢救无效死亡(急性呼吸窘迫综合征2例,难治性休克2例)。20例在伤后2~6 h休克纠正。平衡盐液平均用量:(4 259±268)ml,红细胞悬液(14±2)U,新鲜冰冻血浆(FFP)(800~1 600)ml(FFP∶1 U=100 ml),平均(900±300)ml,血小板(PLT)4~6 U。监测凝血功能、电解质无明显异常。24 h内血乳酸值≤2 mmol/L。复苏成功率83.3%(20/24)。结论:实施DCR可明显提高严重骨折合并未控制性创伤失血性休克患者的救治成功率。液体复苏时应当及时补充FFP,纠正凝血功能异常。

Objective：To investigate clinical effects of damage contral resuscitation （DCR） in rescue multiple fracture with hemorrhagic shock. Methods ：Frem January 2009 to May 2013, clinical data of 24 patients suffered from multiple fracture with hemorrhagic shock were retrospectively reviewed. Among them, 18 cases were male and 6 cases were female, aged from 21 to 48 years old with an average of （32.5-＋4.5）. Small capacity of balanced salt solution were used to maintain systolic ,pres- sure （80-90） mmHg before operation. After control of bleeding with operation, sufficient amount of liquid were rapidly use, and plasma were supplied according to proportion of plasma and red cell suspension （ 1 U：2 U-I U：I U）. After remedy of shock, fluid infusion were sustained negative balance slightly and keep acid-base equilibrium of electrolyte. Dosage of balanced salt solution and blood transfusion before remedy shock were recorded, removal time of lactic acid, coagulation function, incidence and ease fatality of DIC were observed. Results： Four patients were died after 6-18 h into hospital （2 eases died for acute res- piratory distress syndrome and 2 cases for irreversible shock）. Twenty patients with shock were corrected at 2-6 h after injury. Dosage of balanced salt solution was （4 259_＋268） ml, red cell suspension was （14_＋2） U, fresh frozen plasma was （800-1 600） ml （FFP ：1 U =100 ml） averaged （900±300） ml, blood platelet was 4-6 U. Coagulation function and electrolyte were normal. Lactic acid was less than 2 mmol/L within 24 h,the success rate of recovery was 83.3% （20/24）. Conclusion：Performing DCR can obvious improve success rate of remedy serious fracture combined with uncontrolled hemorrhagic shock. Supplementing FFP when correcting coagulation function should be carry out promptly in fluid resuscitation.