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虽说近年来在液体复苏和出血控制等方面取得了重大进展[1],但出血仍然是造成普通创伤病人死亡的重要原因,由出血造成近50%的死亡是发生在受伤后24 h之内,而高达80%的病人是属于术中的创伤死亡[2]。此外,约有25%的严重受伤创伤病人存在过量出血,而导致出血最可能的原因是一种叫急性创伤性凝血病(acute traumatic coagulopathy,ATC)的疾病[3]。即便死亡率如此之高,但创伤后出血目前仍属于可预防的范畴之内[4-5]。说明在早期通过有效控制创伤病人的进行性出血并纠正其凝血功能的进一步恶化,可以大大降低失血性休克(hemorrhagic shock, HS)的死亡率。而近年来提出的限制性液体复苏对HS病人救治率的提高得到广泛认可,但复苏液体的选择仍是目前需攻克的难题。本研究就不同液体限制性复苏对HS病人血栓弹力图及凝血功能的影响作一探讨。
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结果显示,休克发生后,未进行限制性液体复苏前,2组病人一般情况比较无统计学意义(P>0.05)(见表 1)。复苏前后AR组APTT和PT差异均无统计学意义(P>0.05), 而LR组APTT和PT差异均有统计学意义(P < 0.05);2组组内复苏前后TT值差异均有统计学意义(P < 0.05)。复苏前后LR组内血栓弹力图R值差异有统计学意义(P < 0.05),复苏前后2组组内血栓弹力图MA值差异无统计学意义(P>0.05)。复苏前2组外周血的凝血功能和血栓弹力图相关指标差异无统计学意义(P>0.05)。而复苏后1 h,2组病人凝血功能TT值差异有统计学意义(P < 0.05)。2组血栓弹力图的K值差异有统计学意义(P < 0.05),R值和MA值差异无统计学意义(P>0.05)(见表 2~3)。
分组 n 体质量/kg 年龄/岁 体温/℃ 呼吸/
(次/分)心率/
(次/分)收缩压/
mmHg舒张压/
mmHgMAP/
mmHgAR组 20 61.85±12.28 49.5±18.5 36.32±0.29 23.43±2.51 126.11±12.22 70.65±6.12 40.87±3.93 50.73±4.68 LR组 20 65.48±10.71 48.3±16.8 36.65±0.34 23.57±3.31 128.31±13.03 69.13±6.37 39.82±4.37 49.63±4.76 t — 0.99 0.21 3.30 0.15 0.55 0.47 0.78 0.74 P — >0.05 >0.05 < 0.05 >0.05 >0.05 >0.05 >0.05 >0.05 表 1 复苏前2组病人一般情况比较(x±s)
分组 n K R MA 复苏前 AR组 20 3.7±1.3 0.5±0.3 71.1±2.9 LR组 20 3.8±1.2 0.6±0.3 71.4±3.0 t — 0.25 1.05 0.32 P — >0.05 >0.05 >0.05 复苏1 h后 AR组 20 5.2±1.0* 1.0±0.4* 71.0±2.8 LR组 20 4.3±0.7 0.8±0.2* 71.3±2.9 t — 3.29 2.00 0.33 P — < 0.05 >0.05 >0.05 组内配对t检验:*P < 0.05 表 2 复苏前和复苏1 h后2组血栓弹力图相关参数比较(x±s)
分组 n PT/s APTT/s TT/s INR 复苏前 AR组 20 12.50±1.24 26.00±8.36 10.97±1.04 1.04±0.10 LR组 20 12.47±1.19 26.13±8.20 11.13±1.11 1.03±0.10 t — 0.08 0.05 0.47 0.32 P — >0.05 >0.05 >0.05 >0.05 复苏后1 h AR组 20 12.85±1.45 28.56±9.47 14.16±1.30* 1.07±0.12 LR组 20 13.39±1.49* 32.55±10.10* 15.72±1.27* 1.12±0.12* t — 1.16 1.29 3.84 1.32 P — >0.05 >0.05 <0.05 >0.05 组内配对t检验:P < 0.05 表 3 复苏前和复苏1 h后2组外周血凝血功能相关指标比较(x±s)
不同液体限制性复苏对失血性休克病人血栓弹力图及凝血功能的影响
Effects of different fluid restriction resuscitation on coagulation function and thromboelasticdiagram in patients with hemorrhagic shock
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摘要:
目的探讨不同液体限制性复苏对创伤失血性休克病人(HS)的抢救效果及对凝血功能(凝血酶原时间、活化部分凝血活酶时间)和血栓弹力图凝血休克时间[(K)、凝血反应时间(R)、最大凝块强度(MA)等]的影响。 方法选取40例HS病人作为研究对象,随机分为醋酸钠林格液组(AR组)和乳酸钠林格液组(LR组),各20例。AR组复苏液体采用醋酸钠林格液,LR组复苏液体采用乳酸钠林格液,复苏方法均采用限制性液体复苏,分别于开始复苏前及复苏1 h后抽取外周静脉血液样本,通过比较2组病人外周血的凝血功能和血栓弹力图,观察2种液体的复苏效果。 结果复苏开始前,2组病人外周血的凝血功能和血栓弹力图差异均无统计学意义(P>0.05)。复苏1 h后,与LR组相比,AR组病人外周血的凝血酶时间和血栓弹力图的K值差异有统计学意义(P < 0.05)。 结论相比乳酸钠林格液,醋酸钠林格液复苏HS病人,能更好地控制病人的凝血功能及血栓弹力图的相关参数,使得HS病人的液体复苏在早期能取得较好疗效。 Abstract:ObjectiveTo explore the rescue effect of different restrictive fluid resuscitation on traumatic hemorrhagic shock patients (HS) and the effects on coagulation function (prothrombin time, activated partial thrombin time) and thromboelastic diagram (K, R, MA, etc.). MethodsForty HS patients were randomly divided into sodium acetate linge fluid group(AR group) and sodium lactate linge fluid group(LR group), with 20 cases in each group.AR group recovery liquid using sodium acetate ringer's solution, LR group recovery liquid using sodium lactate ringer's solution, adopt restrictive liquid recovery, recovery method respectively and recovery for 1 hour prior to the recovery after extracting peripheral venous blood samples, by comparing the two groups of patients with peripheral blood coagulation function and thrombus elastic figure, to observe the recovery effect of two kinds of liquid. ResultsBefore the onset of resuscitation, there was no statistically significant difference between the two groups in peripheral blood clotting function and thromboelastic diagram (P>0.05).One hour after resuscitation, compared with the LR group, there were statistically significant differences in parameters related to thrombin time and kinetics time in the AR group(P < 0.05). ConclusionsCompared with sodium lactate ringer's solution, sodium acetate ringer's solution for resuscitation of HS patients can better control the coagulation function of patients and related parameters of thromboelastic diagram, so that the liquid resuscitation of HS patients can achieve curative effect in the early stage. -
表 1 复苏前2组病人一般情况比较(x±s)
分组 n 体质量/kg 年龄/岁 体温/℃ 呼吸/
(次/分)心率/
(次/分)收缩压/
mmHg舒张压/
mmHgMAP/
mmHgAR组 20 61.85±12.28 49.5±18.5 36.32±0.29 23.43±2.51 126.11±12.22 70.65±6.12 40.87±3.93 50.73±4.68 LR组 20 65.48±10.71 48.3±16.8 36.65±0.34 23.57±3.31 128.31±13.03 69.13±6.37 39.82±4.37 49.63±4.76 t — 0.99 0.21 3.30 0.15 0.55 0.47 0.78 0.74 P — >0.05 >0.05 < 0.05 >0.05 >0.05 >0.05 >0.05 >0.05 表 2 复苏前和复苏1 h后2组血栓弹力图相关参数比较(x±s)
分组 n K R MA 复苏前 AR组 20 3.7±1.3 0.5±0.3 71.1±2.9 LR组 20 3.8±1.2 0.6±0.3 71.4±3.0 t — 0.25 1.05 0.32 P — >0.05 >0.05 >0.05 复苏1 h后 AR组 20 5.2±1.0* 1.0±0.4* 71.0±2.8 LR组 20 4.3±0.7 0.8±0.2* 71.3±2.9 t — 3.29 2.00 0.33 P — < 0.05 >0.05 >0.05 组内配对t检验:*P < 0.05 表 3 复苏前和复苏1 h后2组外周血凝血功能相关指标比较(x±s)
分组 n PT/s APTT/s TT/s INR 复苏前 AR组 20 12.50±1.24 26.00±8.36 10.97±1.04 1.04±0.10 LR组 20 12.47±1.19 26.13±8.20 11.13±1.11 1.03±0.10 t — 0.08 0.05 0.47 0.32 P — >0.05 >0.05 >0.05 >0.05 复苏后1 h AR组 20 12.85±1.45 28.56±9.47 14.16±1.30* 1.07±0.12 LR组 20 13.39±1.49* 32.55±10.10* 15.72±1.27* 1.12±0.12* t — 1.16 1.29 3.84 1.32 P — >0.05 >0.05 <0.05 >0.05 组内配对t检验:P < 0.05 -
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