右美托咪定联合限制性液体复苏在重症颅脑损伤患者院前急救中的应用效果

Application effect of dexmedetomidine combined with limited fluid resuscitation in pre-hospital care for patients with severe traumatic brain injury

目的探讨右美托咪定联合限制性液体复苏在重症颅脑损伤(STBI)患者院前急救中的应用效果。方法回顾性分析93例STBI患者的临床资料,根据院前急救的方式将患者分为对照组、观察组与联合组,每组31例。对照组患者采用积极液体复苏治疗,观察组患者采用限制性液体复苏治疗,联合组患者采用右美托咪定联合限制性液体复苏治疗。比较急救前、入院即刻3组患者生命体征指标[心率、平均动脉压(MAP)、脉搏血氧饱和度(SpO_(2))]水平变化,以及入院即刻的凝血功能指标[凝血酶原时间(PT)、活化部分凝血活酶时间(APTT)、纤维蛋白原(FIB)、D-二聚体]、血清氧化应激指标[丙二醛、晚期氧化蛋白产物(AOPP)、超氧化物歧化酶(SOD)、谷胱甘肽过氧化物酶(GSH-Px)]、脑脊液神经活动指标[硫化氢、多巴胺、5-羟色胺、乙酰胆碱]、肾功能指标[血清肌酐、尿素氮、β_(2)-微球蛋白(β_(2)-MG)]水平及Glasgow昏迷量表(GCS)评分。术后6个月随访时,采用Glasgow预后量表(GOS)评估患者的预后情况,并分析联合组患者GOS分级与院前时间、右美托咪定使用剂量的相关性。结果入院即刻,3组患者的心率均低于急救前,MAP、SpO_(2)均高于急救前,且联合组与观察组的心率均低于对照组,MAP、SpO_(2)均高于对照组(均P<0.05);联合组与观察组的PT、APTT、D-二聚体水平均短于或低于对照组,FIB水平均高于对照组(均P<0.05);联合组和观察组以上指标差异均无统计学意义(均P>0.05)。联合组脑脊液硫化氢水平及血清肌酐、尿素氮、β_(2)-MG水平均低于观察组与对照组,而脑脊液多巴胺、5-羟色胺、乙酰胆碱水平及GCS评分均高于观察组与对照组(均P<0.05)。3组患者血清丙二醛、AOPP水平由低到高均为联合组、观察组、对照组,血清SOD、GSH-Px水平由高到低均为联合组、观察组、对照组(均P<0.05)。术后随访6个月时,联合组与观察组GOS分级均优于对照组(均P<0.05)。联合组GOS分级与院前时间呈负相关性(P<0.05),与右美托咪定使用剂量无相关性(P>0.05)。结论采用限制性液体复苏进行院前急救可有效地改善STBI患者的血流动力学、氧合能力和凝血功能;在此基础上联合应用右美托咪定可更好地抑制机体的氧化应激反应,促进患者早期神经功能恢复并避免肾功能损伤。

Objective To investigate the application effect of dexmedetomidine combined with limited fluid resuscitation in pre-hospital care for patients with severe traumatic brain injury(STBI).Methods The clinical data of 93 patients with STBI were retrospectively analyzed.According to the approach in pre-hospital care,the patients were divided into control group,observation group and combination group,with 31 cases in each group.Patients in the control group were treated with positive fluid resuscitation,patients in the observation group were treated with limited fluid resuscitation,and patients in the combination group were treated with dexmedetomidine combined with limited fluid resuscitation.Multiple indices of the patients were compared among the three groups,including changes in the levels of vital signs indices(the heart rate,mean arterial pressure[MAP],pulse oxygen saturation[SpO_(2)])before first aid and at admission,as well as the levels of coagulation function indicators(prothrombin time[PT],activated partial thromboplastin time[APTT],fibrinogen[FIB],D-dimer),serum oxidative stress indices(malondialdehyde,advanced oxidation protein product[AOPP],superoxide dismutase[SOD],glutathione peroxidase[GSH-Px]),cerebrospinal fluid neurological activity indicators(hydrogen sulfide,dopamine,5-hydroxytryptamine[5-HT],acetylcholine)and renal function indicators(serum creatinine,urea nitrogen,β_(2)-microglobulin[β_(2)-MG]),and the Glasgow Coma Scale(GCS)score at admission.At the follow-up six months after the operation,the Glasgow Outcome Scale(GOS)was used to assess the prognosis of the patients,and the correlations of patient′s GOS rating with the pre-hospital time and the dosage of dexmedetomidine used in the combination group were analyzed.Results At admission,the heart rate was lower and the MAP and SpO_(2)were higher in the three groups as compared with those before the first aid,and the combination and observation groups exhibited lower heart rates and higher MAP and SpO_(2)than the control group(all P<0.05);PT and APTT were shorter,the levels of D-dimer were lower,and the levels of FIB were higher in the combination and observation groups than in the control group(all P<0.05);there were no statistically significant differences in the indices described above between the combination group and the observation group(all P>0.05).The combination group yielded a lower level of hydrogen sulfide in cerebrospinal fluid,lower serum levels of creatinine,urea nitrogen,andβ_(2)-MG,higher levels of dopamine,5-HT,and acetylcholine in cerebrospinal fluid,and a higher GCS score as compared with the observation and control groups(all P<0.05).Serum levels of malondialdehyde and AOPP increased in the sequence of the combination group,the observation group and the control group,whereas serum levels of SOD and GSH-Px decreased in the sequence of the combination group,the observation group and the control group(all P<0.05).During the period of the postoperative 6-month follow-up,the combination and observation groups were superior to the control group in the GOS rating(all P<0.05).In the combination group,the GOS rating negatively correlated with the pre-hospital time(P<0.05)but did not correlate with the dosage of dexmedetomidine used(P>0.05).Conclusion Applying limited fluid resuscitation into pre-hospital care could effectively improve the hemodynamics,oxygenation capacity and coagulation function of patients with STBI,based on which the combined use of dexmedetomidine can preferably inhibit body oxidative stress response,promote the recovery of early nerve function and avoid renal function impairment for the patients.