摘要：
目的 探讨导向性限制性液体管理策略(RFMS)对严重烧伤合并重度吸入性损伤患者的影响. 方法 将笔者单位2014年12月-2017年12月收治的16例符合入选标准且行RFMS的严重烧伤合并重度吸入性损伤患者作为导向治疗组;将笔者单位2012年12月-2017年12月收治的34例符合入选标准但未行RFMS的严重烧伤合并重度吸入性损伤患者作为常规治疗组,回顾性分析2组患者的病历资料.伤后2d内,导向治疗组采用脉搏轮廓心排血量监测技术监测平均动脉压(MAP)、中心静脉压(CVP)、血管外肺水指数(ELWI)、全心舒张末期容积指数、肺血管通透性指数,常规治疗组患者采用常规方法监测MAP、CVP.伤后3～7d,2组患者均按笔者单位常规方法进行补液治疗,维持血流动力学稳定,导向治疗组患者另以ELWI≤7 mL· kg-1·m-2为液体治疗导向指标实施限制性液体管理策略(RFMS).伤后3～7d,记录2组患者24 h总入量、总出量、总入出量差,血乳酸值及氧合指数;统计伤后3～7d、伤后8～28 d急性呼吸窘迫综合征(ARDS)的发生情况及伤后28 d内机械通气时间、病死情况.对数据行x2检验、t检验及重复测量方差分析. 结果 伤后3、4、5、6、7d,导向治疗组患者的24 h总入量与常规治疗组相近(t=-0.835、-1.618、-2.463、-1.244、-2.552,P＞0.05).伤后3d,2组患者24 h总出量、总入出量差相近(t=0.931、-2.274,P ＞0.05).伤后4、5、6、7d,导向治疗组患者24 h总出量明显高于常规治疗组(t=2.645、2.352、1.847、1.152,P＜0.05).伤后4、5、6、7d,导向治疗组患者24 h总入出量差为(2 928±768)、(2 028 ±1 001)、(2 186 ±815)、(2 071 ±963)mL,明显低于常规治疗组(4 455±960)、(3 434±819)、(3 233±1 022)、(3453±829)mL,t=-4.331、-3.882、-3.211、-4.024,P＜0.05.伤后3、4、5、6、7d,导向治疗组患者血乳酸值与常规治疗组相近(t=0.847、1.221、0.994、1.873、1.948,P＞0.05).伤后3、4d,导向治疗组患者氧合指数为(298±78)、(324±85)mmHg(1 mmHg =0.133 kPa),与常规治疗组的(270±110)、(291±90) mmHg相近(t=1.574、2.011,P＞0.05).伤后5、6、7d,导向治疗组患者氧合指数为(372±88)、(369±65)、(377±39) mmHg,明显高于常规治疗组的(302±103)、(313±89)、(336±78)mmHg,t=3.657、3.223、2.441,P＜0.05.伤后3～7d,导向治疗组发生ARDS的患者略少于常规治疗组,但组间比较,差异无统计学意义(x2=0.105,P＞0.05);伤后8～28 d,导向治疗组发生ARDS的患者明显少于常规治疗组(x2=0.827,P＜0.05).导向治疗组患者伤后28 d内机械通气时间明显短于常规治疗组(t=-2.895,P＜0.05).导向治疗组伤后28 d内死亡患者少于常规治疗组,但组间比较,差异无统计学意义(x 2=0.002,P＞0.05). 结论 在血流动力学稳定的条件下,伤后3～7d实施以ELWI≤7 mL· kg-1·m-2为导向指标的RFMS,能有效降低严重烧伤合并重度吸入性损伤患者后期ARDS的发生率,并缩短机械通气时间.%Objective To explore the influence of directed restrictive fluid management strategy (RFMS) on patients with serious burns complicated by severe inhalation injury.Methods Sixteen patients with serious burns complicated by severe inhalation injury hospitalized in our department from December 2014 to December 2017,meeting the inclusion criteria and treated with RFMS,were enrolled in directed treatment group.Thirty-four patients with serious burns complicated by severe inhalation injury hospitalized in our department from December 2012 to December 2017,meeting the inclusion criteria and without RFMS,were enrolled in routine treatment group.Medical records of patients in 2 groups were retrospectively analyzed.Within post injury day 2,mean arterial pressure (MAP),central venous pressure (CVP),extravascular lung water index (ELWI),global end-diastolic volume index,and pulmonary vascular permeability index of patients in directed treatment group were monitored by pulse contour cardiac output monitoring technology,while MAP and CVP of patients in routine treatment group were monitored by routine method.On post injury day 3 to 7,patients in 2 groups were treated with routine fluid supplement therapy of our Department to maintain hemodynamic stability,and patients in directed treatment group were treated according to RFMS directed with goal of ELWI≤7 mL · kg-1 · m-2.On post injury day 3 to 7,total fluid intake,total fluid output,and total fluid difference between fluid intake and output within 24 h,value of blood lactic acid,and oxygenation index of patients in 2 groups were recorded.Occurrence of acute respiratory distress syndrome (ARDS) on post injury day 3 to 7 and 8 to 28,mechanical ventilation time within post injury day 28,and occurrence of death of patients in 2 groups were counted.Data were processed with chi-square test,t test,and analysis of variance for repeated measurement.Results The total fluid intakes within 24 h of patients in directed treatment group were close to those in routine treatment group on post injury day 3,4,5,6,7 (t =-0.835,-1.618,-2.463,-1.244,-2.552,P ＞0.05).The total fluid outputs and total fluid differences between fluid intake and output within 24 h of patients in 2 groups on post injury day 3 were close (t =0.931,-2.274,P ＞0.05).The total fluid outputs within 24 h of patients in directed treatment group were significantly higher than those in routine treatment group on post injury day 4,5,6,7 (t =2.645,2.352,1.847,1.152,P ＜ 0.05).The total fluid differences between fluid intake and output within 24 h of patients in directed treatment group were (2 928 ±768),(2 028 ± 1 001),(2 186 ±815),and (2 071 ±963) mL,significantly lower than (4 455 ±960),(3 434 ±819),(3 233 ± 1 022),and (3 453 ±829) mL in routine treatment group (t =-4.331,-3.882,-3.211,-4.024,P ＜0.05).The values of blood lactic acid of patients in directed treatment group and routine treatment group on post injury day 3,4,5,6,7 were close (t =0.847,1.221,0.994,1.873,1.948,P ＞0.05).The oxygenation indexes of patients in directed treatment group on post injury day 3 and 4 were (298 ± 78) and (324±85) mmHg (1 mmHg=0.133 kPa),which were close to (270±110) and (291 ±90) mmHg in routine treatment group (t =-1.574,2.011,P ＞ 0.05).The oxygenation indexes of patients in directed treatment group on post injury day 5,6,7 were (372 ±88),(369 ±65),and (377 ±39) mmHg,significantly higher than (302 ± 103),(313 ± 89),and (336 ±78) mmHg in routine treatment group (t =3.657,3.223,2.441,P ＜0.05).On post injury day3,4,5,6,7,patients with ARDS in directed treatment group were less than those in routine treatment group,but with no significantly statistical difference between the 2 groups (x2 =0.105,P ＞ 0.05).On post injury day 8 to 28,patients with ARDS in directed treatment group were significantly less than those in routine treatment group (x2 =0.827,P ＜ 0.05).The mechanical ventilation time within post injury day 28 of patients in directed treatment group was apparently shorter than that in routine treatment group (t =-2.895,P ＜ 0.05).Death of patients in directed treatment group within post injury day 28 was less than that in routine treatment group,but with no significantly statistical difference between the 2 groups (x2 =0.002,P ＞ 0.05).Conclusions Under the circumstance of hemodynamics stability,RFMS directed with goal of ELWI ≤7 mL · kg-1 · m-2 on post injury day 3 to 7 is an useful strategy,which can reduce occurrence rate of ADRS and shorten mechanical ventilation time of patients with serious burns complicated by severe inhalation injury at late stage of burns.
