脉搏轮廓心排血量监测技术在大面积烧伤患者早期治疗中的应用效果

Effects of application of pulse contour cardiac output monitoring technology in early treatment of patients with large area burns

目的分析应用脉搏轮廓心排血量（PiCCO）监测技术的大面积烧伤患者早期血流动力学指标的变化规律及相互关系，探索该技术在大面积烧伤患者休克期治疗中的指导价值。方法2016年5月-2017年5月，笔者单位收治符合入选标准的18例大面积烧伤患者。入院后至伤后7d，采用PiCCO仪监测患者脉搏轮廓心排血量指数（PCCI）、全身血管阻力指数（SVRI）、全心舒张末期容积指数（GEDVI）及血管外肺水指数（EVLWI），4h定标1次并记录参数。计算患者伤后第1、2个24h的补液系数，记录患者伤后1～7d的血乳酸值。对18例患者PCCI、SVRI、GEDVI之间的相关性，SVRI与血乳酸值的相关性进行分析。统计患者的预后情况。对数据行单因素方差分析、单样本t检验及Bonferroni校正、Pearson相关分析、Spearman秩相关分析。结果（1）伤后4～168h，患者PCCI总体比较，差异有统计学意义（F=7．428，P〈0．01）。伤后4、8、12、16、20、24h，患者PCCI分别为（2．4±0．9）、（2．6±1．2）、（2．2±0．6）、（2．6±0．7）、（2．8±0．6）、（2．7±0．7）L·min^-1·m^-2，与正常值4L·min^-1·m^-2比较，明显降低（t=-3．143、-3．251、-11．511、-8．889、-6．735、-6．976．P〈0．05或P〈0．01）。伤后76、80、84、88、92、96h，患者PCCI分别为（4．9±1．5）、（5．7±2．0）、（5．9±1．7）、（5．5±1．3）、（5．3±1．1）、（4．9±1．4）L·min^-1·m^-2，与正常值比较，明显升高（t=2．277、3．142、4．050、4．111、4．128、2．423，P〈0．05或P〈0．01）。其他时间点患者PCCI与正常值接近（P〉0．05）。（2）伤后4～168h，患者SVRI总体比较，差异有统计学意义（F=7．863，P〈0．01）。伤后12、16、20、24、28h，患者SVRI分别为（2298±747）、（2581±498）、（2705±780）、（2773±669）、（3109±1215）dyn·s·cm^-5·m^2，与正常值2050dyn·s·cm^-5·m^2比较，明显升高（t=0．878、3．370、2．519、3．747、3．144，P〈0．05或P〈0．01）。伤后4、8、72、76、80、84、88、92、96h，患者SVRI分别为（1632±129）、（2012±896）、（1381±503）、（1180±378）、（1259±400）、（1376±483）、（1329±385）、（1410±370）、（1346±346）dyn·s·cm^-5·m^2，与正常值比较，明显降低（t=-4．593、-0．112、-5．157、-8．905、-7．914、-5．226、-6．756、-6．233、-7．038，P〈0．01）。其他时间点患者SVRI与正常值接近（P〉0．05）。（3）伤后4～168h，患者GEDVI总体比较，差异无统计学意义（F=0．704，P〉0．05）。伤后8、12、16、20、24h，患者GEDVI与正常值比较，明显降低（t=-3．112、-3．554、-2．969、-2．450、-2．476，P〈0．05）。其他时间点患者GEDVI与正常值接近（P〉0．05）。（4）伤后4～168h，患者EVLWI总体比较，差异有统计学意义（F=1．859，P〈0．01）。伤后16、20、24、28、32、36、40h，患者EVLWI与正常值比较，明显升高（t=4．386、3．335、6．363、4．391、7．513、5．392、5．642，P〈0．01）。其他时间点患者EVLWI与正常值接近（P〉0．05）。（5）患者伤后第1个24h的补液系数为1．90，伤后第2个24h的补液系数为1．39。伤后1～7d患者血乳酸值分别为7．99、5．21、4．57、4．26、2．54、3．13、3．20mmol／L，呈下降趋势。（6）PCCI与SVRI呈明显负相关，r=-0．528，P〈0．01。GEDVI与PCCI呈明显正相关，r=0．577，P〈0．01。GEDVI与SVRI无明显相关性，r=0．081，P〉0．05。血乳酸值与SVRI呈明显正相关，r=0．878，P〈0．01。（7）除1例患者放弃治疗以外，其余患者全部治愈。结论PiCCO监测技术能方便、动态、持续地监测烧伤患者早期血流动力学及容量变化规律，为大面积烧伤患者早期的抗休克等综合治疗提供重要的参考。

Objective To analyze the changes and relationship of early hemodynamic indexes of patients with large area burns monitored by pulse contour cardiac output （PiCCO） monitoring technology, so as to assess the guiding value of this technology in the treatment of patients with large area burns during shock period. Methods Eighteen patients with large area burns, confirming to the study criteria, were admitted to our unit from May 2016 to May 2017. Pulse contour cardiac output index （PCCI） , systemic vascular resistance index （SVRI） , global end-diastolic volume index （GEDVI） , and extravascular lung water index （EVLWI） of patients were monitored by PiCCO instrument from admission to post injury day （PID） 7, and they were calibrated and recorded once every four hours. The fluid infusion coefficients of patients at the first and second 24 hours post injury were calculated. The blood lactic acid values of patients from PID 1 to 7 were also recorded. The correlations among PCCI, SVRI, and GEDVI as well as the correlation between SVRI and blood lactic acid of these 18 patients were analyzed. Prognosis of patients were recorded. Data were processed with one-way analysis of variance, single sample t test and Bonferroni correction, Pearson correlation analysis, and Spearman rank correlation analysis. Results （1） There was statistically significant difference in PCCI value of patients from post injury hour （PIH） 4 to 168 （ F = 7. 428, P 〈 0.01 ）. The PCCI values of patients at PIH4, 8, 12, 16, 20, and 24 were （2.4±0.9）, （2.6±1.2）, （2.2±0.6）, （2.6±0.7）, （2.8±0.6）, and （2.7±0.7） L·min^-1·m^-2, respectively, and they weresignificantly lower than the normal value 4 L·min^-1·m^-2（ t = -3. 143, -3.251, - 11.511, -8.889, -6.735, -6.976,P 〈0.05 orP 〈0.01）. At PIH76, 80, 84, 88, 92, and 96, the PCCI valuesofpatients were （4.9±1.5）, （5.7±2.0）, （5.9 ±1.7）, （5.5±1.3）, （5.3±1. 1）, and （4.9± 1.4） L·min^-1·m^-2, respectively, and they were significantly higher than the normal value （ t = 2. 277, 3. 142, 4. 050, 4.111, 4. 128, 2. 423,P 〈0.05 or P 〈0.01）. The PCCI values of patients at other time points were close to normal value （ P 〉 0.05）. （2） There was statistically significant difference in SVRI value of patients from PIH 4 to 168 （ F =7. 863, P 〈0.01）. The SVRI values of patients at PIH 12, 16, 20, 24, and 28 were （2 298 ±747）, （2 581±498）, （2 705 ±780）, （2 773 ±669）, and （3 109 ± 1 215） dyn·s·cm^-5·m^2, respectively, and they were significantly higher than the normal value 2 050 dyn·s·cm^-5·m^2 （ t =0.878, 3.370, 2.519, 3.747, 3. 144, P 〈0.05 orP 〈0.01）. At PIH 4, 8, 72, 76, 80, 84, 88, 92, and 96, the SVRIvalues of patients were （1 632±129）, （2012±896）, （1 381±503）, （1 180±378）, （1 259 ±400）, （1 376 ±483）, （1 329 ±385）, （1 410±370）, and （1 346±346） dyn·s·cm^-5·m^2, respectively, and they were significantly lower than the normal value （ t = -4.593, -0.112, -5.157, -8.905, -7.914, -5.226, -6.756, -6.233, -7.038, P 〈 0.01）. The SVRI values of patients at other time points were close to normal value （ P 〉 0.05 ）. （3） There was no statistically significant difference in the GEDVI values of patients from PIH 4 to 168 （ F = 0. 704, P 〉0.05）. The GEDVI values of patients at PIH 8, 12, 16, 20, and 24 were significantly lower than normal value （ t = -3.112, -3.554, -2.969, -2.450, -2.476,P 〈0.05）. The GEDVI values of patients at other time points were close to normal value （ P 〉 0.05 ）. （4） There was statistically significant difference in EVLWI value of patients from PIH 4 to 168 （ F = 1. 859, P 〈 0.01 ）. The EVLWI values of patients at PIH 16, 20, 24, 28, 32, 36, and 40 were significantly higher than normal value （ t = 4. 386, 3. 335, 6. 363, 4. 391, 7. 513, 5. 392, 5. 642, P 〈0.01）. The EVLWI values of patients at other time points were close to normal value （ P 〉 0.05）. （5） The fluid infusion coefficients of patients at the first and second 24 hours post injury were 1.90 and 1.39, respectively. The blood lactic acid values of patients from PID 1 to 7 were 7.99, 5.21, 4.57, 4.26, 2.54, 3.13, and 3.20 mmol/L, respectively, showing a declined tendency. （6） There was obvious negative correlation between PCCI and SVRI （ r = -0.528, P 〈0.01）. There was obvious positive correlation between GEDVI and PCCI （ r = 0. 577, P 〈 0.01）. There was no obvious correlation between GEDVI and SVRI （ r = 0. 081, P 〉 0.05 ）. There was obvious positive correlation between blood lactic acid and SVRI （ r = 0. 878, P 〈 0.01 ）. （7） All patients were cured except the one who abandoned treatment. Conclusions PiCCO monitoring technology can monitor the changes of early hemodynamic indexes and volume of burn patients dynamically, continuously, and conveniently, and provide valuable reference for early-stage comprehensive treatment like anti-shock of patients with large area burns.