系统分级复温措施对急诊创伤手术患者体温及预后的影响

Effect of systematic graded rewarming measures on body temperature and prognosis of patients undergoing emergency trauma surgery

目的观察系统分级复温措施对修正创伤评分(RTS)<12分的中重度创伤且需急诊手术患者体温及预后的影响。方法采用前瞻性随机双盲对照研究方法。选择2020年1月至2021年1月在温州医科大学附属第二医院行急诊创伤手术的104例患者作为研究对象,按随机数字表法将患者分为传统复温组和系统分级复温组,每组52例。传统复温组(不进行干预,仅记录体温,当任何节点出现体温<36℃则启动复温流程);系统分级复温组患者则一入院就启动预防措施,并记录体温,当任何节点出现体温<36℃启动分级复温流程。观察两组患者复温效果、凝血功能指标、血气分析、术后麻醉复苏时间的变化及最终转归。结果随时间延长,两组体温逐渐升高;复温后2 h和出院时系统分级复温组体温已均明显高于传统复温组(℃:复温后2 h为36.23±0.77比35.84±0.93,出院时为36.54±0.87比35.82±0.92,均P<0.05),后续低体温发生率明显低于传统复温组〔7.7%(4/52)比25.0%(13/52),P<0.05〕。两组术后活化部分凝血活酶时间(APTT)均较入院时明显缩短(s:系统分级复温组为35.74±8.05比45.55±28.02,P<0.05;传统复温组为38.35±6.48比42.40±13.18,P<0.05);系统分级复温组术中和术后pH值均较入院时明显升高(7.33±0.05、7.36±0.06比7.30±0.07,均P<0.05),而传统复温组术中和术后pH值与较入院时比较差异均无统计学意义(7.31±0.06、7.33±0.06比7.31±0.05,均P>0.05)。系统分级复温组术后凝血酶原时间(PT)和麻醉复苏时间均较传统复温组明显缩短〔PT(s):15.05±2.44比17.94±3.48,麻醉复苏时间(h):14.40±11.76比17.35±10.51,均P<0.05〕,pH值较传统复温组明显升高(7.36±0.06比7.33±0.06,P<0.05)。系统分级复温组较传统复温组有更高的好转率和更低的伤残率(76.9%比65.4%和17.3%比25.0%,均P<0.05)。结论系统分级复温措施能改善急诊创伤需手术患者的低体温状况,降低创伤患者后续低体温的发生率,缩短术后麻醉复苏时间,改善患者凝血功能和血气指标,提高救治率,减少伤残的发生。

Objective To observe the effect of systematic graded rewarming measures on body temperature and prognosis of patients with moderate and severe trauma[revised trauma score(RTS)<12]requiring emergency operation.Methods A prospective randomized double-blind controlled study was conducted.From January 2020 to January 2021,104 patients who underwent emergency trauma surgery in the Second Affiliated Hospital of Wenzhou Medical University were selected as the research object.According to random number table method,the patients were divided into traditional rewarming group and systematic graded rewarming group,with 52 cases in each group.Patients in traditional rewarming group(only record the body temperature without intervention,and start the rewarming process when the body temperature at any time was less than 36℃);the patients in the system graded rewarming group start the preventive measures as soon as they were admitted to the hospital,and record the body temperature.When the body temperature at any time was less than 36℃,start the graded rewarming process.Observe the rewarming effect,coagulation function,blood gas analysis and postoperative anesthesia recovery time of the two groups and final outcome.Results With the extension of time,the body temperature of the two groups increased gradually.The body temperature of the systematic grade rewarming group was significantly higher than that of the traditional rewarming group at 2 hours after rewarming and at discharge(℃:36.23±0.77 vs.35.84±0.93 at 2 hours after rewarming,36.54±0.87 vs.35.82±0.92 at discharge,both P<0.05).The incidence of subsequent hypothermia was significantly lower than that in the traditional rewarming group[7.7%(4/52)vs.25.0%(13/52),P<0.05].The postoperative activated partial thromboplastin time(APTT)of the two groups was significantly shorter than that at admission(s:35.74±8.05 vs.45.55±28.02 in the systematic rewarming group,P<0.05;38.35±6.48 vs.42.40±13.18 in the traditional rewarming group,P<0.05);the intraoperative and postoperative pH values in the systematic rewarming group were significantly higher than those at admission(7.33±0.05,7.36±0.06 vs.7.30±0.07,both P<0.05),while there was no significant difference between the intraoperative and postoperative pH values in the traditional rewarming group and those at admission(7.31±0.06,7.33±0.06 vs.7.31±0.05,both P>0.05).The postoperative prothrombin time(PT)and anesthesia recovery time in the systematic graded rewarming group were significantly shorter than those in the traditional rewarming group[PT(s):15.05±2.44 vs.17.94±3.48,anesthesia recovery time(hours):14.40±11.76 vs.17.35±10.51,all P<0.05],and the pH value was significantly higher than that in the traditional rewarming group(7.36±0.06 vs.7.33±0.06,P<0.05).The systematic graded rewarming group had higher improvement rate and lower disability rate than the traditional rewarming group(76.9%vs.65.4%and 17.3%vs.25.0%,both P<0.05).Conclusion Systematic graded rewarming measures can improve the hypothermia of emergency trauma patients who received surgery,reduce the incidence of subsequent hypothermia of trauma patients,shorten the time of postoperative resuscitation,improve the coagulation function and blood gas indexes,improve the treatment rate,and reduce the incidence of disability.