重度烧伤患者烧伤初期内环境改变及输血治疗的探讨

Investigation of internal environment changes and transfusion therapy at early burn stage of severe burn patients

目的 探讨重度烧伤患者烧伤初期内环境改变及输血治疗的临床意义.方法 选择2010年1月至2014年5月于广东省佛山市第一人民医院收治的大面积重度烧伤初期患者43例为研究对象,纳入研究组.于治疗期间不同时间点检测其血常规、凝血功能、动脉血气分析及血液生化指标等体内内环境变化情况.对其除给予常规烧伤治疗外,同时根据烧伤面积、烧伤程度、手术出血、创面渗血及病情发展情况,给予适当的成分输血治疗,观察患者输血情况并监测其内环境变化.选择同期于同一医院体检的健康受试者43例纳入对照组.对两组的血常规、凝血功能、动脉血气分析及血液生化指标等体内内环境指标进行统计学分析.本研究遵循的程序符合广东省佛山市第一人民医院人体试验委员会制定的伦理学标准,得到该委员会批准,征得受试对象的知情同意,并与之签署临床研究知情同意书.两组受试者年龄、性别构成比等基线资料比较,差异均无统计学意义（P＞0.05）.结果 ①研究组患者在烧伤初期均存在不同程度的凝血功能障碍.其中,烧伤后第1天内其凝血酶原时间（PT）、国际标准化比值（INR）及活化部分凝血酶时间（APTT）均显著高于对照组,且差异均有统计学意义（P＜0.05）;凝血酶时间（TT）除入院时显著高于对照组外,在其他时间点均显著低于对照组（P＜0.05）,且差异均有统计学意义（P＜0.05）;纤维蛋白原（FIB）含量从烧伤后第3天起均显著高于对照组,且差异均有统计学意义（P＜0.05）.②研究组患者烧伤初期亦存在不同程度的酸中毒.其中,烧伤后第1天其血液pH值、全血剩余碱（BE）含量及HCO3-浓度均显著低于对照组,且差异均有统计学意义（P＜0.05）.③与对照组比较,研究组患者烧伤后第1天的红细胞计数、血红蛋白（Hb）水平、血细胞比容（Hct）均较对照组显著增高,差异均有统计学意义（P＜0.05）,反映重度烧伤患者的血液呈浓缩状态,而烧伤后第3天这些指标均明显下降,与烧伤第一天比较,差异均有统计学意义（P＜0.05）;烧伤后第1天,其血小板计数显著升高,与对照组比较,差异有统计学意义（P＜0.05）,随后开始下降,但烧伤后第21天再次升高,与对照组比较,差异有统计学意义（P＜0.05）;烧伤后48 h内,对研究患者输注的成分血以血浆为主,随着治疗时间延长,输血量明显增多,红细胞、血小板和冷沉淀多种成分血均须输注,并且烧伤后第3～14天内,患者红细胞计数、Hb水平及Hct多项指标经输血治疗后均较输血前显著提高,差异均有统计学意义（P＜0.05）.结论 动态监测重度烧伤患者烧伤初期内环境变化情况,及时调整治疗方案,同时给予科学合理的输血治疗是成功救治重度烧伤患者的关键.

Objective To explore the clinical significance of internal environment changes and transfusion therapy at early burn stage of severe burn patients.Methods From January 2010 to May 2014,forty-three early extensive severe burn patients who hospitalized in Foshan First People＇s Hospital of Guangdong Province were enrolled into this study,as study group.Detect the internal environment changes at different time during treatment,such as routine blood test,blood coagulation function,blood gas analysis,blood biochemical indicators and so on.Except of conventional burn treatment,appropriate component transfusion therapy was conducted on patients at the same time,according to its burn surface area and burn degree,volume of surgical hemorrhage,blood oozing from the wound surface and the progression of disease.Analyze the blood transfusion and internal environment changes of early severe burn patients.Forty-three cases of healthy who took health examination in the same hospital during the same period were chose as control group.Statistical analysis was performed on two groups of routine blood test,blood coagulation function,arterial blood gas analysis,blood biochemical indicator and so on.The study protocol was approved by the Ethical Review Board of Investigation in Human Being of Foshan First People＇s Hospital of Guangdong Province.Informed consent was obtained from all participants.There were no significant differences about age and gender between two groups （P〉0.05）.Results ① At the early stage of burn,sever burn patients had different degree of coagulation dysfunction.Within one day after burning,the prothrombin time （PT）,international normalized ratio （INR） and activated partial thromboplastin time （APTT） of study group were higher than t.hose of control group,and the differences were statistically significant （P〈0.05） ; At the time of admission,thrombin time （TT） of study group was higher than that of control group,and the difference was statistically significant （P〈0.05）,and at other time during hospitalization it was lower than that of control group,and the difference was statistically significant （P〈0.05）.Three days after burning,the content of fibrinogen （FIB） of study group was higher than that of control group,and the difference was statistically significant （P〈0.05）.② At the early stage,early sever burn patients also had different degree of acidosis.Within one day after burning,the pH value,concentration of whole blood base excess （BE） and HCO3 of study group were all lower than those of control group,and the differences were statistically significant （P〈0.05）.③ One day after burning,red blood cell count,level of hemoglobin （Hb）,hematocrit （Hct） of study group increased significantly compared with those of control group,and the differences were statistically significant （P〈 0.05）,reflecting the condensed state of blood.And there days after burning,these three indicators decreased compared with those of control group.Within 24 hours after burning,platelet count of study group increased,and the difference was statistically significant （P〈 0.05）,then decreased,and increased again three weeks after burning,and the difference was statistically significant （P〈0.05） ; Within 48 hours after burning,patients with severe burns in study group were transfused plasma in major.And the volume of blood transfusion increased significantly as treatment prolonged,so a variety of blood components were transfused to them,such as red blood cells,platelets and cryoprecipitate.Three days to fourteen days after buring,red blood cell count,level of Hb and Hct of study group improved significantly after transfusion,and the differences were statistically significant （P 〈 0.05）.Conclusions Monitoring the internal environment changes of severe burn patients dynamically at the early stage of burn and adjusting the treatment plan timely,while giving reasonable transfusion therapy at the same time is the key to successful treatment of severe burn patients.