不同液体复苏方案对猪严重烧伤休克期肾功能的影响

Effects of different fluid resuscitation program on renal function in swine during shock stage of severe burn

目的 探讨不同液体复苏方案对猪严重烧伤休克期肾功能的影响. 方法 将24只广西巴马小型猪背部造成40％ TBSAⅢ度烧伤,按随机数字表法分为4组,每组6只.伤后2h,琥珀酰明胶组、羟乙基淀粉组、异体血浆组猪分别以琥珀酰明胶、羟乙基淀粉130/0.4、异体血浆为胶体,按烧伤休克“国内通用”复苏公式复苏,Parkland组猪用乳酸钠林格液按Parkland公式复苏.记录各组猪伤前及伤后第1、2个24 h的血流动力学指标,包括心率、血压、尿量、肺毛细血管楔压、中心静脉压.计算各组猪伤后第1、2个24 h复苏液体量.伤前及伤后4、8、24、48 h,抽取各组猪静脉血,用全自动生化分析仪检测血肌酐及尿素氮;取各组猪尿液,用自动尿液分析仪检测尿微量白蛋白及尿肌酐,并计算二者比值.伤后48 h取各组猪肾脏组织,光学显微镜及电镜下观察肾脏组织病理变化.对数据行重复测量方差分析、单因素方差分析及LSD检验. 结果 (1)各组猪血流动力学指标在伤前及伤后第1、2个24h相近(P值均大于0.05).与组内伤前比较,除异体血浆组猪伤后第1个24 h心率无明显变化(P＞0.05)外,各组猪伤后第1、2个24 h心率均显著升高(P值均小于0.01);除Parkland组猪伤后第1、2个24 h收缩压显著升高(P＜0.05或P＜0.01)外,各组猪伤后第1、2个24 h收缩压、舒张压均无明显变化(P值均大于0.05);除伤后第1个24 h琥珀酰明胶组及异体血浆组猪尿量显著减少(P ＜0.05或P＜0.01)外,各组猪伤后第1、2个24 h尿量无明显变化(P值均大于0.05);各组猪伤后第1、2个24 h中心静脉压及肺毛细血管楔压均显著升高(P＜0.05或P＜0.01).(2)与异体血浆组比较,琥珀酰明胶组、羟乙基淀粉组猪伤后第1、2个24 h复苏液体量无明显变化(P值均大于0.05),Parkland组猪复苏液体量在伤后第1个24 h显著升高、伤后第2个24 h显著降低(P值均小于0.05).(3)与异体血浆组比较,除羟乙基淀粉组猪伤后24 h及Parkland组猪伤后4、8、24、48 h血肌酐显著升高,Parkland组猪伤后4、8h尿素氮显著降低而伤后48 h尿素氮显著升高,Parkland组猪伤后8、24、48 h尿微量白蛋白与尿肌酐比值显著升高(P＜0.05或P＜0.01)外,各组猪各时相点血肌酐、尿素氮、尿微量白蛋白与尿肌酐比值无明显变化(P值均大于0.05).Parkland组猪伤后24 h的血肌酐为(125±16)μmol/L,显著高于伤前的(75±13)μmol/L(P＜0.05).琥珀酰明胶组猪伤后48 h尿素氮为(2.90±1.17) μmol/L,显著低于伤前的(4.60±0.47) μmol/L(P＜0.05);羟乙基淀粉组猪伤后4h尿素氮为(4.82±0.82) μmol/L,显著高于伤前的(3.80±0.73) μmol/L(P＜0.05);异体血浆组猪伤后4、8、48 h尿素氮分别为(4.80±0.33)、(4.92±0.35)、(2.60±0.27) μmol/L,伤后4、8h显著高于伤前的(3.93±0.32) μmol/L,伤后48 h显著低于伤前(P值均小于0.01).Parkland组猪伤后24、48 h尿微量白蛋白与尿肌酐比值分别为(106.7±16.4)、(171.6±36.9) mg/mmol,显著高于伤前的(59.0±3.0) mg/mmol(P值均小于0.01).各组猪其余各时相点血肌酐、尿素氮、尿微量白蛋白与尿肌酐比值与伤前相近(P值均大于0.05).(4)4组猪肾脏组织无明显病理改变. 结论 猪烧伤休克期采用电解质胶体复苏后其肾功能性实验结果显著优于早期采用乳酸钠林格液复苏,电解质胶体复苏方案中应用天然胶体与琥珀酰明胶的结果接近,优于羟乙基淀粉130/0.4.

Objective To explore the effects of different fluid resuscitation program on renal function in swine during shock stage of severe burn.Methods Twenty-four Guangxi Bama miniature swine were inflicted with 40％ total body surface area on the back,and then they were divided into four groups according to the random number table,with 6 swine in each group.At post injury hour (PIH) 2,swine in succinylated gelatin group (S),hydroxyethyl starch group (H),and allogeneic plasma group (A) were respectively resuscitated with succinylated gelatin,hydroxyethyl starch 130/0.4,and plasma according to burn shock “ domestic general” resuscitation formula,and swine in Parkland group (P) were resuscitated with lactated Ringer's solution according to Parkland formula.Hemodynamic indexes including heart rate,blood pressure,urine volume,pulmonary capillary wedge pressure,and central venous pressure before injury,at the first and second PIH 24 were recorded.The volume of resuscitation fluid was calculated at the first and second PIH 24.Blood and urine samples were collected before injury and at PIH 4,8,24,and 48,and then serum creatinine and urea nitrogen were detected by automatic biochemical analyzer,urine microalbumin and urine creatinine were detected by automated urine analyzer and the ratio of which was calculated.The renal tissue of swine in each group was obtained at PIH 48,and the pathologic changes were observed by optical microscopy and electron microscope.Data were processed with analysis of variance of repeated measurement,one-way analysis of variance,and LSD test.Results (1) The hemodynamic indexes of swine in each group were similar before injury and at the first and second PIH 24 (with P values above 0.05).Compared with those before injury,except that the heart rate of swine in group A had no significant change at the first PIH 24 (P ＞ 0.05),the heart rate of swine in each group was significantly increased at the first and second PIH 24 (with P values below 0.01);except that the systolic blood pressure of swine in group P was significantly increased at the first and second PIH 24 (P ＜0.05 orP ＜0.01),there were no significant changes of systolic blood pressure and diastolic blood pressure of swine in each group at the first and second PIH 24 (with P values above 0.05);except that urine volume of swine in groups S and A was significantly decreased at the first PIH 24 (P ＜ 0.05 or P ＜ 0.01),there were no significant change of urine volume of swine in each group at the first and second PIH 24 (with P values above 0.05);pulmonary capillary wedge pressure and central venous pressure of swine in each group were significantly increased at the first and second PIH 24 (P ＜ 0.05 or P ＜ 0.01).(2) Compared with that in group A,the volume of resuscitation fluid of swine in groups S and H had no significant change in the first and second PIH 24 (with P values above 0.05),while it was significantly increased in group P in the first PIH 24 and significantly decreased in the second PIH 24 (with P values below 0.05).(3) Compared with those in group A,except that serum creatinine of swine in group H was significantly increased at PIH 24 and significantly increased in group P at PIH 4,8,24,and 48,urea nitrogen of swine in group P was significantly decreased at PIH 4 and 8 and significantly increased at PIH 48,the ratio of urine microalbumin to urine creatinine of swine in group P was significantly increased at PIH 8,24,and 48 (P ＜ 0.05 or P ＜ 0.01),serum creatinine,urea nitrogen,and the ratio of urine microalbumin to urine creatinine of swine in each group had no significant change at each time point (with P values above 0.05).Serum creatinine of swine in group P was (125 ± 16) μmol/L at PIH 24,which was significantly higher than that before injury [(75 ± 13) μmol/L,P ＜ 0.05].Urea nitrogen of swine in group S was (2.90 ± 1.17) μmol/L at PIH 48,which was significantly lower than that before injury [(4.60 ±0.47) μmol/L,P ＜0.05];urea nitrogen of swine in group H was (4.82 ±0.82)μmol/L at PIH 4,which was significantly higher than that before injury [(3.80 ± 0.73) μmol/L,P ＜ 0.05];urea nitrogen values of swine in group A were respectively (4.80 ± 0.33),(4.92 ± 0.35),and (2.60 ± 0.27) μmol/L at PIH 4,8,and 48,while those at PIH 4,8 were significantly higher and at PIH 48 was significantly lower than the value before injury [(3.93 ± 0.32) μmol/L,with P values below 0.01].The ratios of urine microalbumin to urine creatinine of swine in group P were respectively (106.7 ±16.4) and (171.6 ± 36.9) mg/mmol at PIH 24 and 48,which were significantly higher than the ratio before injury [(59.0 ± 3.0) mg/mmol,with P values below 0.01].The serum creatinine,urea nitrogen,and the ratio of urine microalbumin to urine creatinine of swine in each group at the other time points were similar to those before injury (with P values above 0.05).(4) The renal tissue of swine in the four groups had no obvious pathological change.Conclusions According to the renal function results,fluid resuscitation with electrolyte and colloids are better than with lactated Ringer's solution in swine during shock stage of burn injury,while natural colloids and succinylated gelatin have similar effects,and both are superior to hydroxyethyl starch 130/0.4.