吸入性损伤对大面积烧伤患者休克期液体复苏的影响

Influence of inhalation injury on fluid resuscitation of massive burn patients during shock stage

目的:探讨吸入性损伤对大面积烧伤患者休克期液体复苏的影响。方法:将2009年5月—2019年12月空军军医大学第二附属医院(57例)及延安大学附属医院(17例)收治的共74例大面积烧伤患者(男65例、女9例,年龄21~65岁)纳入本回顾性队列研究。依据临床表现、体征、纤维支气管镜检查结果等将患者分为吸入性损伤组(56例)和非吸入性损伤组(18例)。针对2组患者基线资料中烧伤总面积存在的差异,采用个案-控制匹配以烧伤总面积为标准进行1∶2匹配后吸入性损伤组26例、非吸入性损伤组13例。统计2组患者伤后第1、2、3个24 h患者总补液系数、电解质补液系数、胶体补液系数、水分输入量及电解质胶体比、尿量、累计入出比和伤后24、48、72 h患者心率、呼吸频率、平均动脉压(MAP)、血细胞比容(HCT)。对数据进行重复测量方差分析及Bonferroni校正、 t检验、Fisher确切概率法检验及Mann-Whitney U检验。 结果:(1)匹配后,组间总体比较,2组患者伤后第1~3个24 h总补液系数、水分输入量差异明显( F=4.202、10.671, P<0.05或 P<0.01)。伤后第1、2、3个24 h,2组患者总补液系数、电解质补液系数、胶体补液系数、电解质胶体比相近( t=-1.336、-1.452、-1.998,-0.148、0.141、0.561,0.916、-0.046、-0.509,-1.024、0.208、0.081, P>0.05)。伤后第1、2、3个24 h,吸入性损伤组患者水分输入量分别为(2 996±1 176)、(2 659±1 030)、(2 680±1 509)mL,明显高于非吸入性损伤组的(2 125±898)、(1 790±828)、(1 632±932)mL( t=-2.334、-2.639、-2.297, P<0.05)。(2)匹配后,组间总体比较,吸入性损伤组患者伤后第1~3个24 h尿量、累计入出比分别明显低于、高于非吸入性损伤组( F=12.158、9.111, P<0.01),吸入性损伤组患者伤后24~72 h心率明显高于非吸入性损伤组( F=4.675, P<0.05)。伤后24、48 h,2组患者心率、呼吸频率、MAP、HCT相近( t=-0.039、-1.688,1.399、1.299,-1.741、0.754,-0.677、0.037, P>0.05);伤后第1、2个24 h,吸入性损伤组患者尿量、累计入出比分别明显低于、高于非吸入性损伤组( t尿量=2.421、2.876, t累计入出比=-2.687、-2.943, P<0.05或 P<0.01);伤后72 h,吸入性损伤组患者心率、HCT[(114±13)次/min、0.42±0.06]明显高于非吸入性损伤组[(98±18)次/min、0.38±0.06, t=-3.182、-2.123, P<0.05或 P<0.01],2组患者呼吸频率、MAP相近( t=0.359、1.722, P>0.05);伤后第3个24 h,2组患者尿量、累计入出比相近( t=1.664、-1.895, P>0.05)。 结论:吸入性损伤可导致大面积烧伤患者休克期液体需求增加,适当增加合并吸入性损伤烧伤患者的补液量有助于维持较为理想的尿量。

Objective To explore the influence of inhalation injury on fluid resuscitation of massive burn patients during shock stage.Methods A total of 74 massive burn patients(65 males and 9 females,aged 21 to 65 years)admitted to the Second Affiliated Hospital of Air Force Medical University(n=57)and Yan′an University Affiliated Hospital(n=17)from May 2009 to December 2019 were enrolled in this retrospective cohort study.Patients were divided into inhalation injury group(n=56)and non-inhalation injury group(n=18)based on clinical symptoms,vital signs,and results of bronchofibroscopy.Then 26 patients in inhalation injury group and 13 patients in non-inhalation injury group were 1∶2 matched by case-control matching based on the difference of total burn surface area.The total fluid replacement coefficient,crystalloid replacement coefficient,colloid replacement coefficient,glucose input volume,ratio of crystalloid to colloid,urine volume,and cumulative ratio of input to output volume during the first 24 h post injury,the second 24 h post injury,and the third 24 h post injury,heart rate,respiratory rate,mean arterial pressure(MAP),and hematocrit(HCT)at post injury hour(PIH)24,48,and 72 were recorded and compared between the two groups.Data were statistically analyzed with analysis of variance for repeated measurement and Bonferroni correction,t test,Fisher′s exact probability test,and Mann-Whitney U test.Results(1)After matching,during the first to third 24 h post injury,the total fluid replacement coefficient and glucose input volume of patients in inhalation injury group were significantly higher than those in non-inhalation injury group(F=4.202,10.671,P<0.05 or P<0.01).During the first,second,and third 24 h post injury,the total fluid replacement coefficient,crystalloid replacement coefficient,colloid replacement coefficient,and ratio of crystalloid to colloid were similar between the patients in two groups(t=-1.336,-1.452,-1.998;-0.148,0.141,0.561;0.916,-0.046,-0.509;-1.024,0.208,0.081,P>0.05).During the first,second,and third 24 h post injury,the glucose input volume of patients in inhalation injury group were respectively(2996±1176),(2659±1030),and(2680±1509)mL,which were significantly higher than(2125±898),(1790±828),and(1632±932)mL in non-inhalation injury group(t=-2.334,-2.639,-2.297,P<0.05).(2)After matching,in overall comparison between groups,during the first to third 24 h post injury,the urinary output volumes and cumulative ratios of input to output volume of patients in inhalation injury group were significantly lower or higher than those in non-inhalation injury group,respectively(F=12.158,9.111,P<0.01).At PIH 24,48,and 72,heart rate of patients in inhalation injury group were significantly higher than those in non-inhalation injury group(F=4.675,P<0.05).There were no statistically significant differences in heart rate,respiratory rate,MAP,and HCT between patients in the two groups at PIH 24 and 48(t=-0.039,-1.688,1.399,1.299,-1.741,0.754,-0.677,0.037,P>0.05).During the first and second 24 h post injury,the urine volume and cumulative ratio of input to output volume of patients in inhalation injury group were respectively significantly lower and higher than those in non-inhalation injury group(turine volume=2.421,2.876,tcumulative ratio of input to output volume=-2.687、-2.943,P<0.05 or P<0.01).At PIH 72,the heart rate and HCT of patients in inhalation injury group((114±13)times/min,0.42±0.06)were significantly higher than those in non-inhalation injury group((98±18)times/min,0.38±0.06,t=-3.182,-2.123,P<0.05 or P<0.01),there were no statistically significant differences in respiratory rate and MAP between the patients in two groups(t=0.359,1.722,P>0.05).During the third 24 h post injury,there were no statistically significant differences in urine volume and cumulative ratio of input to output volume between the patients in two groups(t=1.664,-1.895,P>0.05).Conclusions The presence of inhalation injury can lead to increased fluid requirement in massive burn patients during shock stage.An appropriate increase of fluid volume in the fluid resuscitation of burn patients combined with inhalation injury would be beneficial for maintaining ideal urine output.