中心静脉-动脉血二氧化碳含量差对重度烧伤患者削痂术容量复苏的指导意义  

A research of central venous-arterial carbon dioxide difference has guiding significance for severely burn patients in liquid resuscitation during early escharectomy

作　　者：梁冰[1] 曹阳[1] 黄浩然 罗福荣[1] 张志[2] LIANG Bing;CAO Yang;HUANG Haoran;LUO Furong;ZHANG Zhi(Department of Anesthesiology,Guangzhou Red Cross Hospital,the Fourth Affiliated Hospital of Jinan University,Guangzhou 510220,China;不详)

机构地区：[1]广州市红十字会医院暨南大学医学院第四附属医院麻醉科,广州510220 [2]广州市红十字会医院暨南大学医学院第四附属医院烧伤整形外科,广州510220

出　　处：《实用医学杂志》2020年第6期761-766,共6页The Journal of Practical Medicine

基　　金：广东省自然科学基金项目(编号:2016A030313425);广州市科学研究专项项目(编号:201707010491)。

摘　　要：目的通过观察中心静脉-动脉血二氧化碳分压差(Pcv-aCO2)在大面积烧伤患者早期削痂术中液体复苏过程中的变化,探讨Pcv-aCO2对患者术后组织灌注及氧合的影响,为烧伤患者寻求更有效的液体复苏的综合目标方案。方法采用前瞻性观察性研究方法,选择2016年1月至2018年12月广州市红十字会医院烧伤重症加强治疗病房(SICU)收治的大面积烧伤患者128例。所有患者均接受血流动力学监测及目标导向液体治疗,术毕中心静脉氧饱和度(ScvO2)<70%剔出试验。依据T基(诱导前)至T0(术毕)的Pcv-aCO2变化趋势将患者进行分组:第1组(H-H):Pcv-aCO2在T基至T0时间点间持续≥6 mmHg;第2组(L-H):Pcv-aCO2在T基时间点<6 mmHg,T0时间点≥6 mmHg;第3组(H-L):Pcv-aCO2在T基时间点≥6 mmHg,逐步降低至T0时间点<6 mmHg;第4组(L-L):Pcv-aCO2在T基至T0时间点间持续<6 mmHg。记录术毕及术后18 h心率(HR)、血压、中心静脉压(CVP)、心排血指数(CI)、Pcv-aCO2、乳酸等基本生理学指标,计算氧供指数(DO2I)、氧耗指数(VO2I)、氧摄取率(O2ER)、等氧动力学指标,评价Pcv-aCO2与CI的相关性;分析液体复苏治疗后不同Pcv-aCO2水平的组织灌注及氧合变化。结果85例患者均纳入最终分析,第1组(H-H):24例,第2组(L-H):8例,第3组(H-L):17例,第4组(L-L):36例。四组一般资料及APACHEⅡ评分比较差异均无统计学意义。手术时间、总输液量、总出血量组间比较差异均无统计学意义。DO2I在T0时间点L-L,H-L组与另外两组比较差异有统计学意义(P<0.001),O2ER在T0时间点L-L,H-L组与另外两组比较差异有统计学意义(P<0.001),在T18时间点,4组受试者的氧供需指标及氧摄取率指标均无差异。T0时间点、T18时间点HR、血压、CI、CVP组间比较差异均无统计学意义。T0时间点Pcv-aCO2与CI有相关性(r=-0.221),但T18相关性减弱(r=-0.0485),术后0 h至18 h乳酸清除率L-L,H-L组与另外两组比较差异有统计学意义(P<0.001)�Objective By observing the changes of Central venous-arterial partial pressure difference of carbon dioxide[P(cv-a)CO2]in liquid resuscitation during early escharectomy in patients with large-scale burns,We investigate the effect of P(cv-a)CO2 on postoperative tissue perfusion and oxygenation in order to seek a more effective intergrated target plan of liquid resuscitation for burn patients.Methods A prospective observational study was conducted on 128 patients with extensive burns admitted to surgical intensive care unit(SICU)of Guangzhou Red Cross hospital from January 2016 to December 2018.All patients received hemodynamic monitoring and goal-directed fluid therapy,patients with central venous oxygen saturation(ScvO2)<70%were excluded.Patients were divided into the following groups according to the changing trend of Pcv-aCO2 between T base(before induction)and T0(after surgery):Group 1(H-H):Pcv-aCO2≥6 mmHg between T base and T0;Group 2(L-H):Pcv-aco2<6 mmHg at T base and≥6 mmHg at T0;Group 3(H-L):Pcv-aCO2≥6 mmHg at T base and<6 mmHg at T0.Group 4(L-L):Pcv-aCO2<6 mmHg between T base and T0.Postoperative T0 and T18 basic physiological indicators such as heart rate(HR),blood pressure,central venous pressure(CVP),cardiac output index(CI),PcvaCO2 and lactic acid were recorded.Oxygen dynamic indicators such as oxygen delivery index(DO2 I),oxygen consumption index(VO2 I),oxygen uptake rate(O2 ER)and so on were calculated.Pearson correlation analysis was used to evaluate the correlation between Pcv-aCO2 and CI.The change of tissue perfusion and oxygenation with different levels of Pcv-aCO2 after fluid resuscitation were analyzed.Results All 85 patients were included in the final analysis,including 24 patients in group 1(H-H),8 patients in group 2(L-H),17 patients in group 3(H-L),and36 patients in group 4(L-L).There were no statistical significance among the four groups in the general information and APACHE II scores.Comparison among groups in time of operation,total infusion volume and total bleeding volume were

关 键 词：烧伤 中心静脉-动脉血二氧化碳分压差 复苏 

分 类 号：R448[医药卫生—诊断学]