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当今社会创伤仍然是导致死亡的主要原因之一,死亡通常在受伤后的6 h内发生[1]。大量出血在短时间内导致病人血容量迅速丢失,病人很快进入休克状态,继而导致死亡。该过程是一个复杂的病理生理过程,其发病机制与细胞能量代谢、组织酸中毒、全身的炎症反应、凝血等有密切的关系,如果不予以及时干预,最终会导致机体多个器官及系统的异常改变甚至功能衰竭[2-3]。限制性液体复苏可以提高创伤失血性休克的成功率[4-9]。碳酸氢钠林格液作为一种新型晶体溶液,在有效地扩充血容量的同时还能够减轻组织损伤和组织细胞酸中毒。但关于碳酸氢钠林格液复苏对创伤失血性休克疗效的影响目前报道甚少。本研究采用碳酸氢钠林格液与乳酸钠林格液复苏创伤失血性休克病人,观察外周血细胞因子、动脉血乳酸、凝血功能等的差异,评估碳酸氢钠林格液对创伤失血性休克病人的复苏效果。现作报道。
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2组病人复苏前一般资料比较差异均无统计学意义(P>0.05)(见表 1)。
分组 n 体质量/kg 年龄/岁 体温/℃ 呼吸/(次/分) 心率/(次/分) 观察组 24 66.75±7.53 44.13±15.05 36.02±0.53 24.06±1.74 128.84±3.99 对照组 24 64.66±8.27 48.19±8.27 36.22±0.48 23.41±1.62 130.57±4.18 t — 0.92 1.16* 1.37 1.34 1.47 P — >0.05 >0.05 >0.05 >0.05 >0.05 分组 n 收缩压/mmHg 舒张压/mmHg 创伤严重程度评分 血红蛋白/(g/L) 红细胞/(×1012/L) 观察组 24 71.77±3.92 43.73±2.87 25.51±3.02 78.37±4.75 2.89±0.39 对照组 24 72.68±5.38 44.62±3.11 24.24±2.64 79.26±5.22 2.95±0.56 t — 0.67 1.03 1.55 0.62 0.43 P — >0.05 >0.05 >0.05 >0.05 >0.05 *示t′值 表 1 2组病人一般情况比较(x±s)
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复苏前2组病人血清IL-4、IL-6、IL-10、TNF-α比较差异均无统计学意义(P>0.05)。复苏1 h后,观察组除TNF-α,其余因子均较复苏前显著增高(P < 0.01),对照组只有IL-6和IL-10较复苏前显著增加(P < 0.01)。观察组复苏1 h后外周血细胞因子IL-4和IL-10水平高于对照组,IL-6和TNF-α低于对照组,差异均有统计学意义(P < 0.05)(见表 2)。
分组 n IL-4/pg/mL IL-6/pg/mL IL-10/pg/mL TNF-α/ng/mL 复苏前 观察组 24 5.65±1.19 25.40±4.48 22.84±3.19 11.30±2.30 对照组 24 5.58±1.20 25.28±5.36 22.93±2.61 11.42±1.66 t — 0.20 0.08 0.11 0.21 P — >0.05 >0.05 >0.05 >0.05 复苏1 h后 观察组 24 6.67±1.34** 29.21±4.65** 29.49±4.51** 11.82±2.34 对照组 24 5.86±1.19 32.91±6.61** 26.71±3.31** 13.36±2.52 t — 2.21 2.24 2.43 2.19 P — < 0.05 < 0.05 < 0.05 < 0.05 组内配对t检验:**P < 0.01 表 2 2组不同液体限制性复苏失血性休克病人复苏前、复苏1 h后外周血炎症因子的比较(x±s)
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2组病人复苏前动脉血乳酸值、PLT、PT、FIB比较差异均无统计学意义(P>0.05),复苏后1 h后,观察组动脉血乳酸值显著低于对照组(P < 0.01),而PLT、PT、FIB比较差异无统计学意义(P>0.05)(见表 3)。
分组 n 乳酸/(mmol/L) PLT /(×109/L) PT/s FIB/(g/L) 复苏前 观察组 24 5.68±1.00 124.50±14.35 13.32±1.19 3.15±0.69 对照组 24 5.92±0.83 122.63±14.65 13.48±1.20 3.11±0.67 t — 0.90 0.45 0.46 0.20 P — >0.05 >0.05 >0.05 >0.05 复苏后1 h 观察组 24 3.86±0.76** 111±10.77** 14.51±0.87** 2.52±0.52** 对照组 24 5.23±0.86 109±13.44** 14.88±1.19** 2.56±0.53** t — 5.85 0.57 1.23 0.26 P — < 0.01 >0.05 >0.05 >0.05 组内配对t检验:**P < 0.01 表 3 2组动脉血乳酸值、PLT、PT、FIB水平的比较(x±s)
碳酸氢钠林格液限制性复苏对创伤失血性休克内环境的影响
Effect of limited resuscitation with sodium bicarbonate Ringer's solution on the internal environment of traumatic hemorrhagic shock
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摘要:
目的比较乳酸钠林格液、碳酸氢钠林格液限制性复苏对创伤失血性休克病人外周血细胞因子、动脉血乳酸值、血小板计数及凝血功能,为筛选相对理想的复苏液体提供参考。 方法采用前瞻性对照研究,纳入48例创伤失血性休克住院病人,采用随机数据表法分为观察组和对照组,各24例。其中,观察组应用碳酸氢钠林格液进行复苏,对照组应用乳酸钠林格液进行复苏,2组均采用限制性补液复苏策略。分别测定复苏前、复苏1 h后病人的外周血中白细胞介素(IL)-4、IL-6、IL-10、肿瘤坏死因子(TNF)-α水平以及动脉血的乳酸值、外周血小板计数、血浆凝血酶原时间、纤维蛋白原水平。 结果复苏1 h后,观察组除TNF-α,其余因子均较复苏前显著增高(P < 0.01),对照组只有IL-6和IL-10较复苏前显著增加(P < 0.01)。观察组复苏1 h后外周血细胞因子IL-4和IL-10水平高于对照组,IL-6和TNF-α低于对照组(P < 0.05)。复苏后1 h后,观察组动脉血乳酸值显著低于对照组(P < 0.01),而血小板计数、血浆凝血酶原时间、纤维蛋白原比较差异无统计学意义(P>0.05)。 结论碳酸氢钠林格液早期复苏创伤失血性休克病人能更好地抑制外周血中炎症因子的表达,并且能够更好地降低血乳酸值,比乳酸钠林格液复苏更有优势。 Abstract:ObjectiveTo compare the effects of limited resuscitation with sodium lactate Ringer's solution and sodium bicarbonate Ringer's solution on peripheral blood cytokines, arterial blood lactate, platelet count and coagulation function in patients with traumatic hemorrhagic shock, to provide reference for screening relatively ideal resuscitation fluid. MethodsIn a prospective controlled study, 48 inpatients with traumatic hemorrhagic shock were selected and divided into observation group and control group using random number table method (24 cases in each group).Sodium bicarbonate Ringer's solution was used for resuscitation in the observation group, sodium lactate Ringer's solution was used in the control group, and limited fluid resuscitation strategy was used in both groups.The levels of interleukin (IL)-4, IL-6, IL-10, tumor necrosis factor (TNF)-α in peripheral blood and arterial blood lactate value, peripheral platelet count, plasma prothrombin time and fibrinogen level were measured before resuscitation and 1 hour after resuscitation. ResultsOne hour after resuscitation, except TNF-α, the other factors in observation group were significantly higher than those before resuscitation (P < 0.01), while only IL-6 and IL-10 in control group were significantly higher than those before resuscitation (P < 0.01);the levels of IL-4 and IL-10 in peripheral blood in observation group were higher than those in control group, while the levels of IL-6 and TNF-α in observation group were lower than those in control group (P < 0.05);the level of arterial blood lactate in observation group was significantly lower than that in control group (P < 0.01), but there was no significant difference in platelet count, plasma prothrombin time and fibrinogen level(P>0.05). ConclusionsEarly resuscitation with sodium bicarbonate Ringer's solution in patients with traumatic hemorrhagic shock can better inhibit the expression of inflammatory factors in peripheral blood and reduce the blood lactate value, which is better than sodium lactate Ringer's solution for resuscitation. -
表 1 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) 观察组 24 66.75±7.53 44.13±15.05 36.02±0.53 24.06±1.74 128.84±3.99 对照组 24 64.66±8.27 48.19±8.27 36.22±0.48 23.41±1.62 130.57±4.18 t — 0.92 1.16* 1.37 1.34 1.47 P — >0.05 >0.05 >0.05 >0.05 >0.05 分组 n 收缩压/mmHg 舒张压/mmHg 创伤严重程度评分 血红蛋白/(g/L) 红细胞/(×1012/L) 观察组 24 71.77±3.92 43.73±2.87 25.51±3.02 78.37±4.75 2.89±0.39 对照组 24 72.68±5.38 44.62±3.11 24.24±2.64 79.26±5.22 2.95±0.56 t — 0.67 1.03 1.55 0.62 0.43 P — >0.05 >0.05 >0.05 >0.05 >0.05 *示t′值 表 2 2组不同液体限制性复苏失血性休克病人复苏前、复苏1 h后外周血炎症因子的比较(x±s)
分组 n IL-4/pg/mL IL-6/pg/mL IL-10/pg/mL TNF-α/ng/mL 复苏前 观察组 24 5.65±1.19 25.40±4.48 22.84±3.19 11.30±2.30 对照组 24 5.58±1.20 25.28±5.36 22.93±2.61 11.42±1.66 t — 0.20 0.08 0.11 0.21 P — >0.05 >0.05 >0.05 >0.05 复苏1 h后 观察组 24 6.67±1.34** 29.21±4.65** 29.49±4.51** 11.82±2.34 对照组 24 5.86±1.19 32.91±6.61** 26.71±3.31** 13.36±2.52 t — 2.21 2.24 2.43 2.19 P — < 0.05 < 0.05 < 0.05 < 0.05 组内配对t检验:**P < 0.01 表 3 2组动脉血乳酸值、PLT、PT、FIB水平的比较(x±s)
分组 n 乳酸/(mmol/L) PLT /(×109/L) PT/s FIB/(g/L) 复苏前 观察组 24 5.68±1.00 124.50±14.35 13.32±1.19 3.15±0.69 对照组 24 5.92±0.83 122.63±14.65 13.48±1.20 3.11±0.67 t — 0.90 0.45 0.46 0.20 P — >0.05 >0.05 >0.05 >0.05 复苏后1 h 观察组 24 3.86±0.76** 111±10.77** 14.51±0.87** 2.52±0.52** 对照组 24 5.23±0.86 109±13.44** 14.88±1.19** 2.56±0.53** t — 5.85 0.57 1.23 0.26 P — < 0.01 >0.05 >0.05 >0.05 组内配对t检验:**P < 0.01 -
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