产后出血患者的液体管理及其继发腹高压的危险因素

Fluid management and risk factors of intra-abdominal hypertension secondary to postpartum hemorrhage

目的探讨产后出血患者的液体管理方法及发生腹高压的危险因素。方法2013年1月至2015年1月，昆明市第一人民医院重症监护病房（intensive care unit，ICU）收治的64例产后出血患者纳入分析，根据收住ICU当时的腹内压分为腹高压组和非腹高压组。患者进入ICU后24h液体负平衡均≥1000ml。比较腹高压组与非腹高压组的基本情况（年龄、是否子痫前期、是否行子宫切除术、是否行动脉导管栓塞术）、腹内压、肝肾功能及住院时间。比较所有患者24h液体负平衡治疗前后的腹内压和肝肾功能。采用独立样本，检验、配对，检验和，检验进行统计分析，采用Logistic回归分析产后出血患者发生腹高压的危险因素。结果64例患者中，15例（23．4％，15／64）在收住ICU当时有腹高压，25例（39．1％，25／64）患子痫前期，1例（1．6％，1／64）行子宫切除术，16例（25．0％，16／64）行动脉导管栓塞术。64例患者进入ICU之前12h内，平均失血量为（4022±1275）ml，晶体液输入量为（8894±2597）ml，胶体液输入量为（343±87）ml，血制品输入量为（1370±346）ml。总液体输入量为（10607±2825）m1，总液体出量为（5176±2334）ml。平均每小时人液量为（884±235）ml，平均每小时尿量为（431±195）ml。Logistic回归分析显示，子痫前期（OR=5．30，95％CI：1．15～24．45）、平均每小时输液量〉1000ml（OR=5．34，95％CI：1．14～24．92）、平均每小时尿量≤200ml（〈200ml时，OR=0．17，95％C／：0．05～0．58）是产后出血患者发生腹高压的危险因素。非腹高压组在ICU的住院时间[（3．33±1．84）与（8．73±9．77）d]和总住院时间[（10．29±3．96）与（18．13±9．88）d]均较腹高压组短（t值分别为-3．73和-4．55，P值均〈0．05）。经过24h液体负平衡治疗后腹内压[（6．67±4．61）与（8．47±5．85）mmHg（1mmHg=0．133kPa），t=7．76]、总胆红素[（14．31±14．91）与（20．96±37．56）μmol／L，t=2．02]、尿素氮[（6．49±5．18）与（7．57±7．07）mmol／L，t=2．72]、肌酐[（105．57±81．66）与（140．61±126．14）μmol／L，t=5．33]均较治疗前降低，白蛋白[（24．45±4．80）与（21．35±5．69）g／L，t=-4．47]升高，差异均有统计学意义（P值均〈0．05）。结论产后出血患者合并子痫前期、大量输液及液体出量过少，均是发生腹高压的危险因素。腹高压对肝肾功能不利，并延长住院时间。采用液体负平衡治疗能降低腹内压，改善肝肾功能。

Objective To investigate fluid management and risk factors of intra-abdominal hypertension （IAH） after postpartum hemorrhage. Methods Clinical data of 64 patients of postpartum hemorrhage who were admitted to Intensive Care Unit （ICU） of the First People＇s Hospital of Kunming from January 2013 to January 2015 were collected. The patients were divided into IAH group and non-IAH groupbased on intra-abdominal pressure on admission to ICU. Diuresis or dialysis were offered to patients whose output exceeded 1 000 ml of their input after hospitalization. The background information, including maternal age, existence of pre-eclampsia and whether hysterectomy and transcatheter arterial embolization were performed, intra-abdominal pressure, liver and renal function and length of stay in hospital between the two groups were compared. The intra-abdominal pressure and liver and renal function before and 24 h after negative fluid administration of all subjects were compared as well. Independent-samples t test, paired-samples t test, Chi- square test and logistic regression analysis were applied for statistics. Results Among all of the 64 patients, 15（23.4%） presented with IAH on admission, 25 （39.1%） were complicated with preeclampsia, one （1.6%） had the uterus removed, and 16 （25.0%） had transcatheter arterial embolization performed. Within 12 h before admission, the average blood loss of the 64 women was （4 022±1 275） ml, crystal solution input was （8 894±2 597） ml, colloidal fluid input was （343±87） ml, blood products input was （1 370±346） ml, total fluid input was （10 607±2 825） ml, total fluid output was （5 176±2 334） ml, average fluid input per hour was （884±235） ml and average urinary production per hour was （431±195） ml. Logistic regression analysis showed that pre-eclampsia （OR=5.30, 95%CI： 1.15-24.45）, average fluid input per hour 〉 1 000 ml （OR=5.34, 95%CI： 1.14-24.92） and average urinary production per hour ≤ 200 ml （〉200 ml, OR=0.17, 95%CI： 0.05-0.58） were risk factors of IAH. The non-IAH group showed shorter length of stay in ICU [（3.33 ±1.84） vs （8.73±9,77） d] and shorter length of stay in hospital [（10.29-t-3.96） vs （18.13±9.88） d] than IAH group （t= - 3.71 and - 4.55, both P〈0.05）. After 24 hours negative fluid administration, the intra-abdominal pressure [（6.67± 4.61） vs （8.47 ±5.85） mmHg （1 mmHg=0.133 kPa）, t=7.76], total serum bilirubin level [（14.31 ±14.91） vs （20.96±37.56） μ mol/L, t=2.02], blood urea nitrogen level [（6.49±5.18） vs （7.57 ±7.07） mmol/L, t=2.72] and creatinine level [（105.57±81.66） vs （140.61±126.14） μmol/L, t=5.33] were all significantly decreased comparing with before negative fluid administration, but the serum albumin level rised up [（24.45±4.80） vs （21.35 ±5.69） g/L, t=- - 4.47]. Conclusions Pre-eclampsia, massive fluids input and too little output per hour in patients complicated with postpartum hemorrhage were risk factors of IAH. IAH is harmful to liver and kidney, and makes the length of stay in hospital longer. However, negative fluid administration could decrease the intraabdominal pressure and improve the function of liver and kidney.