非控制性失血休克复苏策略和护理干预

摘要

目的 评估不同方法液体复苏和护理干预对非控制性失血休克结局的影响.方法 采用回顾性队列研究,分析2011年6月—2016年6月手术治疗的855例非控制性失血休克胸腹多发伤患者.纳入对象分为两组:低压复苏组573例,术前限制性液体复苏,收缩压控制在80~85mmHg,输液总量<1000mL;传统复苏组282例,术前强制性输液,输液总量>2000mL,收缩压维持在85mmHg以上.比较分析两组血液和输液需要量、病死率、术后早期并发症和凝血象.结果 总病死率9.2%(79/855),53.2%死于失血性休克并凝血病.存活病例治愈的主要并发症:凝血病131例、腹腔间隙综合征11例、过负荷补液71例、急性肺损伤70例、轻度心脏衰竭46例.低压复苏组与传统复苏组输血输液需要量、病死例数、术后早期异常指标并需要处理的例数、凝血象检查、ICU时间≥7d例数相比,差异有统计学意义(P<0.05).结论 非控制性失血休克采用"损害控制性复苏"即低压复苏和止血性复苏,可降低病死率和并发症发生率.护理干预重点是掌握复苏压力、时间、方法和凝血因子全面及时补充;并发症护理重点为"致死三联征"即凝血病、低体温和酸中毒.%Objective To investigate the clinical application and nursing effect of hypotensive resuscitation in treating patients with uncontrolled hemorrhagic shock.Methods A retrospective study was used to investigate 855 patients with uncontrolled hemorrhagic shock from Jun.2011 to Jun.2016,who were divided into 2 groups.In hypotensive resuscitation group(573),preoperative"limited fluid resuscitation"was used to maintain a systolic blood pressure of 80-85mmHg,and the amount of fluid was less than 1000mL.In control group(282),preoperative"aggressive fluid resuscitation"was used with fluid amount over 2000mL,and systolic blood pressure was maintained above 85mmHg.Parameters such as blood demand quantity,death rate,early postoperative complications and blood coagulation were compared between the two groups.Results Overall mortality was 9.2%(79/855).Of the deaths,53.2%died of exsanguination associated with coagulopathy.In the survivors,cured postoperative complica-tions included coagulopathy(131),abdominal compartment syndrome(11),overload transfusion(71),acute lung in-jury(70)and mild cardiac failure(46).Between the two groups,the amount of fluid required,the death cases,early postoperative complication,laboratory coagulation parameters,and prolonged ICU time(≥7d)were all significant(P<0.05).Conclusion To manage uncontrolled hemorrhagic shock,hypotensive resuscitation with hemostatic re-suscitation is a wise option,which decreases the mortality and morbidity.Key measure for nursing care is the control of blood pressure and time of fluid resuscitation,and the administration of coagulative factors.Key points for compli-cation care is"lethal triad"including coagulopathy,hypothermia,and acidosis.