目的 探究不同液体复苏方法治疗严重骨盆骨折失血性休克的效果及预后分析.方法 前瞻性选取2021年6月—2023年6月笔者医院收治的严重骨盆骨折失血性休克患者96例为研究对象,其中男性56例,女性40例;年龄18～55岁,平均38.6岁;道路交通伤51例,高处坠落伤24例,挤压伤21例.患者入院后均完成止血、骨折外固定等外科急救处理,常规监测生命体征、建立静脉通道、完善血常规等术前检查.随机数字表法分为研究组48例与对照组48例.对照组患者进行常规快速液体复苏,及时补充足量的平衡液、胶体液、悬浮红细胞、血浆等,研究组予以限制性液体复苏,前期适当输入高渗氯化钠溶液,而后输入平衡液等.比较两组入院时、复苏后3 d生命体征指标,凝血指标与急性生理与慢性健康Ⅱ(APACHEⅡ)评分,电解质水平以及入院时、复苏后30 min、1 h炎症因子水平,观察两组预后指标差异.结果 两组复苏后3 d全心舒张末期容量指数(GEDVI)、心脏指数(CI)、心排血量(CO)、氧合指数(Pa02/FiO2)、MAP、中心静脉压(CVP)与入院时比较均升高,血乳酸(LAC)、HR与入院时比较均降低(P＜0.05);且研究组复苏后3d上述生命体征指标改变幅度优于对照组(P＜0.05).两组复苏后3 d TT、PT、APTT与入院时比较均升高,APACHE Ⅱ评分与入院时比较均降低(P＜0.05);且研究组复苏后3 d TT、PT、APTT、APACHE Ⅱ评分均低于对照组(P＜0.05).两组复苏后3 d Na+与入院时比较均升高,K+与入院时比较均降低(P＜0.05);但两组复苏后3 d Cl-、Mg2+、Na+、K+比较差异无统计学意义(P＞0.05).重复测量方差分析结果显示,两组y干扰素(y-IFN)、IL-4、IL-6、TNF-α的时点、组间、交互效应比较差异有统计学意义(P＜0.05),两组复苏后30 min、1h的y-IFN、IL-4、IL-6、TNF-α与入院时相比均显著升高,且复苏后1h的y-IFN、IL-4、IL-6、TNF-α高于复苏后30 min(P＜0.05),但研究组复苏后30 min、1 h的y-IFN、IL-4、IL-6、TNF-α均低于对照组(P＜0.05).两组急性呼吸窘迫综合征、弥散性血管内凝血、多器官功能障碍综合征、急性肾衰竭、肺部感染、腹腔感染发生率比较差异无统计学意义(P＞0.05),但研究组并发症总发生率与病死率均低于对照组(8.3％vs.37.5％,2.1％vs.16.7％,P＜0.05).结论 限制性急诊液体复苏方法治疗严重骨盆骨折失血性休克具有较好应用效果,可有效改善患者生命体征,纠正凝血功能紊乱状态,减轻炎症反应,降低并发症发生风险,改善预后.
Clinic effect and prognosis analysis of different emergency fluid resuscitation methods for hemorrhagic shock following severe pelvic fractures
Objective To explore the clinical effect and prognosis of different emergency fluid resuscitation methods in the treatment of hemorrhagic shock following severe pelvic fractures.Methods A total of 96 patients with severe pelvic fractures and hemorrhagic shock admitted to our hospital from Jun.2021 to Jun.2023 were pro-spectively selected as the study objects.Among the 96 patients,56 were male and 40 were female,with an average age of 38.6 years.The main cause of injuries was road traffic accidents(51 cases),followed by falls(24 cases)and crushing injuries(21 cases).The patients were divided into study group(48 cases)and control group(48 ca-ses)according to the random number table method.After admission,all patients underwent surgical emergency treatment such as hemostasis,external fixation of fractures,routine monitoring of vital signs,establishment of venous channels,and blood routine exam.Patients in the control group were subjected to routine rapid fluid resuscitation,supplemented with sufficient equilibrium fluid,colloidal fluid,suspended red blood cells,plasma,etc.,while those in the study group were subjected to restricted fluid resuscitation,with appropriate input of hypertonic sodium chloride solution in the early stage and then input of equilibrium fluid.The vital sign indexes at 3 d after resuscitation,coagu-lation indexes,acute physiological and chronic health Ⅱ(APACHE Ⅱ)scores,electrolyte levels,and inflammatory factors levels at admission,30 min and 1 h after resuscitation were compared between the two groups.The differ-ences in prognostic indexes were also observed.Results The whole heart end diastolic volume index(GEDVI),cardiac index(CI),cardiac output volume(CO),oxygenation index(Pa02/FiO2),mean arterial pressure(MAP)and central venous pressure(CVP)at 3 d after resuscitation increased while blood lactate(LAC)and heart rate(HR)decreased,all revealing significant difference compared with those on admission(P＜0.05);moreover the abovementioned vital signs were much better in the study group than in the control group(all P＜0.05).At 3 d after resuscitation,TT,PT and APTT were higher than those on admission and APACHE-Ⅱ scores were lower(all P＜0.05);further comparison between study and control groups showed much lower results of TT,PT,APTT and A-PACHE-Ⅱ scores in the study group(all P＜0.05).At 3 d after resuscitation,the levels of Na+increased and K+decreased compared with those on admission(P＜0.05),however,comparison between the two groups showed no significant difference regarding Cl-,Mg2+,Na+and K+levels(P＞0.05).Repeated measurement ANOVA showed that there were statistically significant differences in the timing,intergroup and interaction effects of Y-interferon(y-IFN),interleukin-4(IL-4),interleukin-6(IL-6)and tumor necrosis factor-α(TNF-α)between the two groups(P＜0.05).The y-IFN,IL-4,IL-6 and TNF-α levels at 30 min and 1 h after resuscitation in both groups were signifi-cantly higher than those before treatment,and moreover much higher at 1 h after resuscitation than at 30 min after re-suscitation(all P＜0.05).At both 30 min and 1 h after resuscitation,the y-IFN,IL-4,IL-6 and TNF-α levels in the study group were all lower than those in the control group(all P＜0.05).As for the complications of acute respirato-ry distress syndrome(ARDS),disseminated intravascular coagulation(DIC),multiple organ dysfunction syndrome(MODS),acute renal failure(ARF),pulmonary infection and abdominal infection,the separate incidence showed no significant difference between the two groups(P＞0.05),but the total incidence of complications and mortality rate in the study group were lower than those in the control group(8.3％vs.37.5％and 2.1％vs.16.7％,both P＜0.05).Conclusion The limited emergency fluid resuscitation method for hemorrhagic shock after severe pelvic fractures has a good therapeutic effect,which can effectively improve the vital signs of patients,correct the coagula-tion disorder,reduce the inflammatory reaction,reduce the risk of complications,and improve the prognosis.
NETL
NSTL
万方数据
