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不同目标血压复苏对创伤失血性休克患者外周血炎性因子和血流动力学的影响

Effects of different target blood pressure resuscitation on peripheral blood inflammatory factors and hemodynamics in patients with traumatic hemorrhagic shock
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摘要 目的探讨创伤失血性休克患者限制性液体复苏的目标血压水平。方法选择2016年1月至2018年12月蚌埠医学院第一附属医院收治的60例创伤失血性休克患者。按入院顺序编号,根据随机数字表法选择符合标准的研究对象依次入组,所有患者入院后均接受醋酸钠林格液复苏,根据复苏不同目标平均动脉压(MAP)分为低MAP(60mmHg≤MAP<65mmHg,1mmHg=0.133kPa)、中MAP(65mmHg≤MAP<70mmHg)和高MAP(70mmHg≤MAP<75mmHg)3组,每组20例。复苏30min未达目标MAP者予以排除,并顺延补充病例。检测各组患者限制性液体复苏前及复苏30min和60min血清炎性因子表达并实时监测血流动力学变化,推测最合适的复苏血压水平。变量的相关性采用Pearson相关分析。结果液体复苏前,3组患者血流动力学和血清炎性因子表达量差异均无统计学意义;复苏30min分别达到目标血压水平并维持30min。随液体复苏时间延长,3组患者中心静脉压(CVP)、心排血量(CO)和心排血指数(CI)均缓慢升高,在复苏30min前后基本达到平稳状态,以高MAP组和中MAP组升高更为显著。3组患者血清炎性因子表达量均随液体复苏时间延长呈持续升高趋势。复苏30min时,中MAP组在抑制促炎因子肿瘤坏死因子-α(TNF-α)、白细胞介素-6(IL-6)表达和促进抑炎因子IL-10表达方面均优于低MAP组和高MAP组〔TNF-αmRNA(2^-ΔΔCt):0.21±0.13比0.69±0.34、0.57±0.35,IL-6mRNA(2^-ΔΔCt):0.35±0.31比0.72±0.39、0.59±0.42,IL-10mRNA(2^-ΔΔCt):1.25±0.81比0.61±0.46、0.82±0.53,均P<0.05〕,但在促进IL-4表达方面3组间比较差异无统计学意义。复苏60min时,中MAP组在抑制TNF-α、IL-6表达和促进IL-10表达方面亦均优于低MAP组和高MAP组〔TNF-αmRNA(2^-ΔΔCt):0.72±0.35比1.05±0.54、1.03±0.49,IL-6mRNA(2^-ΔΔCt):0.57±0.50比1.27±0.72、1.01±0.64,IL-10mRNA(2^-ΔΔCt):1.41±0.90比0.81±0.48、0.94±0.61,均P<0.05〕;中MAP组在促进IL-4表达方面优于高MAP组(2^-ΔΔCt:1.3 Objective To investigate the target blood pressure level of restrictive fluid resuscitation in patients with traumatic hemorrhagic shock. Methods Sixty patients with traumatic hemorrhagic shock admitted to the First Affiliated Hospital of Bengbu Medical College from January 2016 to December 2018 were enrolled. All patients were resuscitated with sodium acetate ringer solution after admission. According to the difference of mean arterial pressure (MAP) target, the patients were divided into low MAP (60 mmHg ≤ MAP < 65 mmHg, 1 mmHg = 0.133 kPa), middle MAP (65 mmHg ≤ MAP < 70 mmHg) and high MAP (70 mmHg ≤ MAP < 75 mmHg) groups by random number table using the admission order with 20 patients in each group. Those who failed to reach the target MAP after 30-minute resuscitation were excluded and supplementary cases were deferred. The restrictive fluid resuscitation phase was divided into three phases: before fluid resuscitation, liquid resuscitation for 30 minutes and 60 minutes. The most suitable resuscitation blood pressure level was further speculated by monitoring the inflammatory markers and hemodynamics in different periods in each group of patients. Pearson correlation analysis was used to detect the correlation of variables. Results Before fluid resuscitation, there was no significant difference in hemodynamics or expressions of serum cytokines among the three groups. Three groups of patients were resuscitated for 30 minutes to achieve the target blood pressure level and maintain 30 minutes. With the prolongation of fluid resuscitation time, the central venous pressure (CVP), cardiac output (CO) and cardiac index (CI) were increased slowly in the three groups, and reached a steady state at about 30 minutes after resuscitation, especially in the high MAP group and the middle MAP group. The expressions of serum inflammatory factors in the three groups were gradually increased with the prolongation of fluid resuscitation time. Compared with the low MAP group and the high MAP group, after 30 minutes of resu
作者 邵志林 杜召辉 王如意 王振杰 何先弟 汪华学 李言 邱兆磊 李磊 郑传明 程峰 Shao Zhilin;Du Zhaohui;Wang Ruyi;Wang Zhenjie;He Xiandi;Wang Huaxue;Li Yan;Qiu Zhaolei;Li Lei;Zheng Chuanming;Cheng Feng(Department of Emergency Surgery,the First Affiliated Hospital of Bengbu Medical College,Bengbu 233000,Anhui,China;Department of Intensive Care Unit,the First Affiliated Hospital of Bengbu Medical College,Bengbu 233000,Anhui,China;Department of Pathophysiology,Bengbu Medical College,Bengbu 233000,Anhui,China)
出处 《中华危重病急救医学》 CAS CSCD 北大核心 2019年第4期428-433,共6页 Chinese Critical Care Medicine
基金 安徽省科技计划攻关项目(1604a0802089).
关键词 限制性液体复苏 失血性休克 创伤 平均动脉压 中心静脉压 Restrictive fluid resuscitation Hemorrhagic shock Trauma Mean arterial pressure Central venous pressure
作者简介 通信作者:王振杰,Email:ahbyfywzj@163.com.
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