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目的探讨限制性液体管理策略(restrictive fluid management strategy,RFMS)对严重烧伤早期肺脏并发症的防治作用。方法收集2012年6月至2014年12月入住西南医院烧伤科的严重烧伤患者32例作为对照组,收集2015年1月至2016年7月入住西南医院烧伤科的严重烧伤患者29例作为限制组。采用非随机前瞻性观察研究法分析:两组休克期(伤后2 d内)治疗方法相同,回吸收期(伤后3~10 d)对照组常规治疗,限制组实施RFMS,即适当控制补液总量+通过利尿促进体液排出。采用脉搏轮廓持续心输出量(pulseindicator continuous cardiac output,Pi CCO)容量监护仪监测并记录两组患者伤后10 d内血流动力学指标;记录伤后10 d每日液体入/出量并计算液体净平衡;记录实验室生化检查、病原菌培养结果;统计回吸收期呼吸机使用情况;分析患者伤后2周内急性呼吸窘迫综合征(acute respiratory distress syndrome,ARDS)、肺部感染发生率。结果限制组回吸收期每日液体净平衡和每日累积液体净平衡均低于对照组。限制组回吸收期全心舒张末期容积指数(global end-diastolic volume index,GEDI)在各时间点上均低于对照组,对照组在伤后7d达正常值上限且持续在高水平维持,限制组于伤后7 d达峰值,此后呈下降趋势。对照组回吸收期血管外肺水指数(external venous lung water index,ELWI)均高于正常值上限,限制组仅在伤后7~9 d高于正常值上限。对照组和限制组回吸收期出现ELWI异常总天数的百分比分别为52.34%和35.34%,二者比较差异具有统计学意义(P<0.01)。回吸收期对照组15例使用呼吸机,限制组6例,差异具有统计学意义(P<0.05)。回吸收期呼吸机使用总天数的百分比分别为对照组41.02%,限制组18.53%,二者差异有统计学意义(P<0.01)。两组患者伤后2周内对照组12例发生ARDS,限制组4例;对照组14例发生肺部感染,限制组5例;二者比较差异均有统计学意义(P<0.05)。两组患者回吸收期心脏指数(CI)均高于正常值上限,平均动脉压(MAP)处于正常值范围。结论适当的RFMS可有效减少严重烧伤回吸收期液体净平衡,促进体液回吸收和减轻容量负荷,对预防和减轻早期严重烧伤肺水肿与肺部并发症具有重要作用。
Objective To investigate the preventive and therapeutic effects of restrictive fluid management strategy (RFMS) on pulmonary complications in patients with severe burns. Methods Thirty-two patients with severe burns admitted to Department of Burnology, Southwest Hospital from June 2012 to December 2014 were selected as the control group. Twenty-nine patients with severe burns admitted to the Department of Burns, Southwest Hospital from January 2015 to July 2016 were recruited as the control group . Non-randomized prospective observational study analysis: The two groups during the shock period (within 2 days after injury) the same treatment, back to the absorption period (3 to 10 days after injury) control group conventional treatment, restricted group implementation of RFMS, that appropriate control of rehydration Total + Promotes bodily discharge through diuretic. The hemodynamic parameters of the two groups were monitored and recorded within 10 days after injury by pulse capacity continuous cardiac output monitor (Pulse CICC). The daily fluid intake / discharge volume was recorded and calculated The net balance of the liquid was recorded. The biochemical tests and the results of pathogen culture were recorded. The respirator usage during the recovery period was calculated. The incidence of acute respiratory distress syndrome (ARDS) and pulmonary infection within 2 weeks after injury was analyzed. Results Restricted group back to the absorption of daily net balance of liquid and daily cumulative liquid net balance were lower than the control group. In the control group, the global end-diastolic volume index (GEDI) was lower than that of the control group at each time point, and the control group reached the upper limit of normal value and maintained at a high level on the 7th day after injury The group reached its peak on the 7th day after injury and then declined. In the control group, the extrinsic lung water index (ELWI) was higher than the upper limit of normal, and the limit group was only higher than the upper limit of normal within 7-9 days after injury. The percentage of total days of abnormal ELWI in control group and control group returned to absorption was 52.34% and 35.34%, respectively. There was significant difference between the two groups (P <0.01). The control group returned to the absorption of ventilator in 15 cases, the control group of 6 patients, the difference was statistically significant (P <0.05). The percentage of total days of respirator use in resuscitation was 41.02% in the control group and 18.53% in the control group, respectively. The difference was statistically significant (P <0.01). ARDS was found in 12 cases in control group and 4 cases in control group within 2 weeks after injury. There were 14 cases in control group with pulmonary infection and 5 cases in control group. There was significant difference between the two groups (P <0.05). The return of heart index (CI) in both groups were higher than the upper limit of normal and mean arterial pressure (MAP) was in the normal range. Conclusion Appropriate RFMS can effectively reduce the net balance of fluid during the period of severe burn back-up, promote the absorption of body fluid and reduce the volume load, and play an important role in preventing and reducing pulmonary edema and pulmonary complications of early severe burn.