成人大面积烧伤后急救复苏十倍法补液公式的创建与应用

Establishment and application of the tenfold rehydration formula for emergency resuscitation of adult patients after extensive burns

目的探讨成人大面积烧伤后急救复苏十倍法补液公式的科学性和可行性。方法采用回顾性观察性研究方法。收集解放军总医院第四医学中心2016年12月—2019年12月收治的170例大面积烧伤成年患者[男135例、女35例,年龄(42±14)岁]的烧伤总面积[30%~100%体表总面积(TBSA)]和体重(45~135 kg)资料。将45~135 kg中的每一体重(编程步长为1 kg)与烧伤总面积为30%~100%TBSA中的每一面积(编程步长为1%TBSA)配对后的6461对模拟数据,代入4个公认补液公式——Parkland公式、Brooke公式、解放军第三〇四医院公式和第三军医大学公式与2个急救补液公式——世界卫生组织烧伤技术工作小组(TWGB)提出的大面积烧伤患者急救简化复苏方案(以下简称TWGB公式)和该文作者提出的十倍法补液公式,计算伤后8 h内补液速度(以下简称补液速度),结果以烧伤总面积编程步长为10%TBSA进行展示。以4个公认补液公式的计算结果为合理补液速度,计算并比较采用2个急救补液公式计算的补液速度的准确率。利用烧伤总面积分别为30%、100%TBSA时采用十倍法补液公式计算结果为合理补液速度时对应的最大体重,将45~135 kg分为3个段,比较各个体重分段中采用2个急救补液公式计算的补液速度的准确率。当2个急救补液公式计算的补液速度均不合理时,比较两者补液速度的差异。统计前述170例患者中前述3个体重分段分布;利用前述170例患者的烧伤总面积和体重数据,同前计算并比较采用2个急救补液公式计算的补液速度的准确率。对数据进行McNemar检验。结果烧伤总面积分别为30%、40%、50%、60%、70%、80%、90%、100%TBSA时,体重为45~135 kg的情况下,采用2个急救补液公式计算的补液速度均没有超过4个公认补液公式的计算结果中的最大值;TWGB公式计算的补液速度不随烧伤总面积的变化而改变,十倍法补液公式计算的补液速度不随体重的变化而改变。6461对模拟数据代入显示,根据十倍法补液公式计算的补液速度的准确率为43.09%(2784/6461),明显高于TWGB公式的2.07%(134/6461),χ^(2)=2404.80,P<0.01。当体重为45~62、63~93 kg时,根据十倍法补液公式计算的补液速度的准确率分别为100%(1278/1278)、68.42%(1506/2201),均明显高于TWGB公式的0(0/1278)、0.05%(1/2201),χ^(2)=1276.00、1501.01,P<0.01;当体重为94~135 kg时,根据十倍法补液公式计算的补液速度的准确率为0(0/2982),明显低于TWGB公式的4.46%(133/2982),χ^(2)=131.01,P<0.01。当2个急救补液公式计算的补液速度均不合理时,采用十倍法补液公式计算的大部分补液速度大于TWGB公式的计算结果,占79.3%(2808/3543)。170例患者中,体重为45~62、63~93、94~135 kg者所占比例分别为25.29%(43/170)、65.88%(112/170)、8.82%(15/170)。170例患者中,采用十倍法补液公式计算的补液速度的准确率为69.41%(118/170),明显高于TWGB公式的3.53%(6/170),χ^(2)=99.36,P<0.01。结论应用十倍法补液公式计算成人大面积烧伤后急救复苏补液速度相对4个公认补液公式简便,优于TWGB公式,适合非烧伤专业的一线医护人员院前抢救大面积烧伤成年患者时应用,值得推广。

Objective To explore the scientificity and feasibility of the tenfold rehydration formula for emergency resuscitation of adult patients after extensive burns.Methods A retrospective observational study was conducted.The total burn area(30%-100%total body surface area(TBSA))and body weight(45-135 kg)of 170 adult patients(135 males and 35 females,aged(42±14)years)with extensive burns admitted to the Fourth Medical Center of PLA General Hospital from December 2016 to December 2019 were collected.The 6461 pairs of simulated data obtained after pairing each body weight in 45 to 135 kg(programmed in steps of 1 kg)with each area in 30%to 100%TBSA(programmed in steps of 1%TBSA)were plugged into four recognized rehydration formulas--Parkland's formula,Brooke's formula,the 304th PLA Hospital formula,and the Third Military Medical University formula and two emergency rehydration formulas--the simplified first aid resuscitation plan for extensive burn patients proposed by the World Health Organization's Technical Working Group on Burns(TWGB,hereinafter referred to as the TWGB formula)and the tenfold rehydration formula proposed by the author of this article to calculate the rehydration rate within 8 hours after injury(hereinafter referred to as the rehydration rate),with results being displayed by a programming step of 10%TBSA for the total burn area.Taking the calculation results of four recognized rehydration formulas as the reasonable rehydration rate,the accuracy of rehydration rates calculated by two emergency rehydration formulas were calculated and compared.The body weight of 45-135 kg was divided into three segments by the results of maximum body weight at a reasonable rehydration rate calculated by the tenfold rehydration formula when the total burn area was 30%and 100%TBSA,respectively.The accuracy of rehydration rate calculated by two emergency rehydration formulas in each body weight segment was compared.When the rehydration rates calculated by two emergency rehydration formulas were unreasonable,the differences in rehydration rates between the two were compared.Statistical distribution of the aforementioned three body weight segments in the aforementioned 170 patients was counted.Using the total burn area and body weight data of the aforementioned 170 patients,the accuracy of rehydration rate calculated by two emergency rehydration formulas was calculated and compared as before.Data were statistically analyzed with McNemar test.Results When the total burn area was 30%,40%,50%,60%,70%,80%,90%,and 100%TBSA,respectively,and the body weight was 45-135 kg,the rehydration rates calculated by two emergency rehydration formulas did not exceed the maximum of the calculated results of four recognized rehydration formulas;the rehydration rate calculated by the TWGB formula did not change accordingly with total burn area,while the rehydration rate calculated by the tenfold rehydration formula did not change accordingly with body weight.Substituting 6461 pairs of simulated data showed that the accuracy of rehydration rate calculated by the tenfold rehydration formula was 43.09%(2784/6461),which was significantly higher than 2.07%(134/6461)of the TWGB formula,χ^(2)=2404.80,P<0.01.When the body weights were 45-62 kg and 63-93 kg,the accuracy rates of rehydration rate calculated by the tenfold rehydration formula were 100%(1278/1278)and 68.42%(1506/2201),respectively,which were significantly higher than 0(0/1278)and 0.05%(1/2201)of the TWGB formula,χ^(2)=1276.00,1501.01,P<0.01;when the body weight was 94-135 kg,the accuracy rate of rehydration rate calculated by the tenfold rehydration formula was 0(0/2982),which was significantly lower than 4.46%(133/2982)of the TWGB formula,χ^(2)=131.01,P<0.01.When the rehydration rates calculated by two emergency rehydration formulas were both unreasonable,the rehydration rate calculated by the tenfold rehydration formula was greater than that calculated by the TWGB formula in most cases,accounting for 79.3%(2808/3543).Among the 170 patients,the proportions of those weighing 45-62,63-93,and 94-135 kg were 25.29%(43/170),65.88%(112/170),and 8.82%(15/170),respectively.Among the 170 patients,the accuracy rate of rehydration rate calculated by the tenfold rehydration formula was 69.41%(118/170),which was significantly higher than 3.53%(6/170)of the TWGB formula,χ^(2)=99.36,P<0.01.Conclusions Applying the tenfold rehydration formula to calculate the emergency rehydration rate in adults after extensive burns is simpler than four recognized rehydration formulas,and is superior to the TWGB formula.The tenfold rehydration formula is suitable for the front-line medical staffs that are not specialized in burns in pre-admission rescue of adult patients with extensive burns,which is worth popularizing.