碳酸氢钠林格液在高原地区休克伴高乳酸血症患者乳酸靶向复苏策略中的作用研究

Clinical study on sodium bicarbonate Ringer injection as a lactate targeted resuscitation strategy for treatment of shock patients with hyperlactatemia in plateau areas

目的观察碳酸氢钠林格液对高原地区休克伴高乳酸血症患者行乳酸靶向复苏策略的疗效。方法选择2019年1月至2021年5月武威市人民医院急救中心收治的259例休克伴高乳酸血症患者作为研究对象。根据复苏晶体液选择不同将患者分碳酸氢钠林格液组〔122例,给予碳酸氢钠林格液1500~3000 mL静脉滴注(静滴)〕和常规晶体液组(137例,给予0.9%生理盐水和复方氯化钠溶液1500~3000 mL静滴)。比较两组住院时间、病死率和多器官功能障碍综合征(MODS)发生率的差异,并观察两组治疗前和治疗后6、12、24、48 h pH值、血乳酸(Lac)、剩余碱(BE)、Na^(+)、Cl^(-)、HCO3-、平均动脉压(MAP)、乳酸清除率(LCR)等生理参数的变化。结果碳酸氢钠林格液组住院时间较常规晶体液组明显缩短〔d:6.0(3.0,10.0)比9.0(3.5,15.0),P<0.05〕,病死率较常规晶体液组明显降低〔18.9%(23/122)比29.9%(41/137),P<0.05〕,MODS发生率较常规晶体液组降低〔54.1%(66/122)比64.2%(88/137)〕,但差异无统计学意义(P>0.05)。随治疗时间延长,观察期间两组pH值、BE、MAP、LCR、HCO3-均呈升高趋势,Lac呈降低趋势,各时间点与治疗前比较差异均有统计学意义(均P<0.05),且治疗6 h内和6~12 h变化趋势显著,直至恢复到正常参考值范围。与常规晶体液组比较,碳酸氢钠林格液组治疗后48 h pH值、BE均明显降低〔pH值:7.37±0.11比7.40±0.07,BE(mmol/L):-1.8(-2.5,1.3)比-0.5(-1.9,1.8),均P<0.05〕,治疗后48 h MAP和治疗后6 h LCR均明显升高〔MAP(mmHg,1 mmHg≈0.133 kPa):83.92±4.66比82.07±7.97,LCR(%):50.0(26.1,76.5)比24.3(0.3,24.8)〕,治疗后24 h Na^(+)和治疗后12 h Cl^(-)亦均明显降低〔Na^(+)(mmol/L):140.08±5.13比142.12±5.03,Cl^(-)(mmol/L):99.36±4.46比104.05±11.06,均P<0.05〕。结论采用碳酸氢钠林格液对高原地区休克伴高乳酸血症患者进行扩容治疗,可快速改善酸中毒,更好地维持酸碱平衡;以Lac、LCR为靶向复苏策略,可防止液体矫枉过正或不足,从而为临床治疗提供科学依据,避免造成组织细胞进一步损害,缩短住院时间,降低病死率,且疗效较常规晶体液更显著。

Objective To observe the effect of using sodium bicarbonate Ringer solution in lactate targeted resuscitation strategy for treatment of patients with shock and hyperlactatemia at plateau areas.Methods A total of 259 patients with shock and hyperlactatemia treated in the Emergency Center of Wuwei People's Hospital from January 2019 to May 2021 were selected as the research objects.According to the difference in choice of resuscitation crystal solution,the patients were divided into a sodium bicarbonate Ringer solution group(122 cases)given 1500-3000 mL intravenous drip(IVDRIP)of sodium bicarbonate Ringer solution,and a conventional crystalloid group(137 cases)given 1500-3000 mL IVDRIP of 0.9%normal saline containing compound sodium chloride.The differences in the length of hospital stay,mortality and incidence of multiple organ dysfunction syndrome(MODS)were compared between the two groups,the changes of pH value,blood lactic acid(Lac),base excess(BE),Na^(+),Cl^(-),HCO3-,mean arterial pressure(MAP)and lactate clearance rate(LCR),etc.physiological parameters in the two groups were observed before treatment and 6,12,24,48 hours after treatment.Results The length of hospital stay of the sodium bicarbonate Ringer solution group was significantly shorter than that of the conventional crystalloid group[days:6.0(3.0,10.0)vs.9.0(3.5,15.0),P<0.05],the mortality was significantly lower than that of the conventional crystalloid group[18.9%(23/122)vs.29.9%(41/137),P<0.05],and the incidence of MODS was lower than that of the conventional crystalloid group[54.1%(66/122)vs.64.2%(88/137)],but the difference was not statistically significant(P>0.05).During the observation period of the two groups,with the extension of treatment time,pH value,BE,MAP,LCR and HCO3-showed an upward trend,Lac showed a downward trend,the difference between each time point after treatment compared with the corresponding index before treatment was statistically significant(all P<0.05),and the changing trends within 6 hours and 6-12 hours after treatment were significant until recovering to the normal range.Compared with the conventional crystalloid group,pH and BE levels were obviously lower in the sodium bicarbonate Ringer group 48 hours after treatment[pH value:7.37±0.11 vs.7.40±0.07,BE(mmol/L):-1.8(-2.5,1.3)vs.-0.5(-1.9,1.8)both P<0.05],48 hours after treatment MAP and 6 hours after treatment LCR were significantly elevated in the sodium bicarbonate Ringer group[MAP(mmHg,1 mmHg≈0.133 kPa):83.92±4.66 vs.82.07±3.97,LCR(%):50.0(26.1,76.5)vs.24.3(0.3,24.8)],24 hours after treatment Na^(+)and 12 hours after treatment Cl^(-)were markedly decreased in the Ringer group[Na^(+)(mmol/L):140.08±5.13 vs.142.12±5.03),Cl^(-)(mmol/L):99.36±4.46 vs.104.05±11.06,both P<0.05].Conclusion Application of sodium bicarbonate Ringer solution to expand the volume of patients with shock and hyperlactatemia at plateau areas can improve or correct the acidosis quickly and maintain acid-base balance better;taking Lac and LCR as targeted resuscitation strategies not only can prevent liquid hypercorrection or liquid insufficiency but also can provide scientific basis for clinical treatment,avoid further damage to tissue cells,shorten the length of hospital stay and reduce mortality,thus using sodium bicarbonate Ringer solution is more effective than conventional crystalloid solution in these shock patients with hyperlactactemia at plateau areas.