本文選題：失血性休克 + 多發(fā)傷��； 參考：《天津醫(yī)科大學(xué)》2017年碩士論文

【摘要】：目的:探討中重度顱腦損傷合并多發(fā)傷失血性休克患者的最佳液體復(fù)蘇策略。方法:回顧性分析我科于2007年1月至2015年1月治療的128例顱腦損傷合并多發(fā)傷失血性休克患者,根據(jù)不同的液體復(fù)蘇方式分為積極液體復(fù)蘇組(A組)和限制液體復(fù)蘇組(B組),限制液體復(fù)蘇組又依據(jù)選擇復(fù)蘇液種類的不同,分為B1組(HES+LR)和B2組(HES+7.5%HS),補(bǔ)液的量化調(diào)控標(biāo)準(zhǔn):嚴(yán)密監(jiān)測血流動力學(xué),限制液體復(fù)蘇組將平均動脈壓控制在70-80mmHg,中心靜脈壓控制在6-8cmH2O,維持48小時(shí),積極液體復(fù)蘇組輸注LR和HES,比例2-3:1,迅速恢復(fù)血容量,血壓控制在患者基礎(chǔ)血壓水平,中心靜脈壓控制在8-12cmH2O,余治療兩組基本相同。對三組間的GCS昏迷評分、休克指數(shù)、凝血功能、CT顱內(nèi)出血進(jìn)展率、ARDS、MODS發(fā)生率及傷后6個(gè)月GOS評分等進(jìn)行對比研究。結(jié)果:三組對比休克指數(shù)在治療前后都明顯改善,比較無顯著差異(P0.05)。三組間在顱內(nèi)出血進(jìn)展率、GCS評分、ARDS、MODS發(fā)生率上比較,存在顯著差異(P0.05),其中A組出血進(jìn)展人數(shù)16例、ARDS 15例、MODS 14例均多于B1、B2組,GCS評分為7.1±2.4則不如B1、B2組,B1、B2組在顱內(nèi)出血進(jìn)展率、ARDS、MODS發(fā)生率、GCS評分上比較則無顯著性差異。在凝血功能指標(biāo)比較上,限制液體復(fù)蘇組(B組)亦優(yōu)于積極液體復(fù)蘇組(A組),而復(fù)蘇液的選擇上B1組(HES+LR)與B2組(HES+7.5%高滲鹽水HS)則無顯著性差異。24小時(shí)補(bǔ)液量上三組對比具有顯著性差異,其中B1、B2組對比差異亦具有顯著性(P0.05)。隨訪6個(gè)月時(shí)以GOS評分評價(jià),限制液體復(fù)蘇組好于積極液體復(fù)蘇組。結(jié)論:對于中重度顱腦損傷合并多發(fā)傷失血性休克患者積極液體復(fù)蘇及限制性液體復(fù)蘇均能有效改善休克狀態(tài),但在凝血功能、顱內(nèi)出血進(jìn)展率、ARDS、MODS發(fā)生率及傷后6個(gè)月GOS評分方面,采用限制性液體復(fù)蘇的方法對患者更有益處。而限制性液體復(fù)蘇時(shí)采用7.5%HS能減少輸注的液體量,也許可防止休克早期對機(jī)體內(nèi)環(huán)境的不利影響。
[Abstract]:Objective: to investigate the optimal fluid resuscitation strategy in patients with moderate and severe craniocerebral injury complicated with multiple hemorrhagic shock. Methods: a retrospective analysis of 128 patients with multiple traumatic hemorrhagic shock after craniocerebral injury was performed from January 2007 to January 2015. According to different ways of fluid resuscitation, they were divided into active fluid resuscitation group (group A) and restricted fluid resuscitation group (group B). B _ 1 group (HES LRR) and B2 group (HES 7.5) were divided into two groups: hemodynamics was closely monitored, mean arterial pressure was controlled at 70-80 mm Hg in fluid resuscitation group, and central venous pressure was controlled at 6-8 cm H _ 2O for 48 hours. In the positive fluid resuscitation group, LR and HES were infused with a ratio of 2 to 3: 1, the blood volume recovered rapidly, the blood pressure was controlled at the basic blood pressure level of the patients, and the central venous pressure was controlled at 8-12 cm H _ 2O. The other two groups were basically the same. The scores of GCS coma, shock index, coagulation function and the progression rate of intracranial hemorrhage in CT were compared among the three groups. The incidence of ARDS mods and the GOS score at 6 months after injury were compared between the three groups. Results: the contrastive shock index of the three groups was significantly improved before and after treatment, and there was no significant difference between the three groups (P 0.05). The rate of progression of intracranial hemorrhage and the incidence of ARDS mods were compared among the three groups. There was a significant difference (P < 0.05). There was no significant difference in the rate of progression of intracranial hemorrhage and the incidence of ARDS mods and GCS score in group A (n = 16) and ARDS group (n = 15) and mods group (n = 14), which was higher than that in group B _ (1) or B _ (2) group with a GCS score of 7.1 鹵2.4, which was not significantly different from that in group B _ (1) and B _ (1) B _ (2) group. On the comparison of coagulation function indexes, The resuscitation group was also superior to the positive fluid resuscitation group (group A), but the choice of resuscitation fluid was not significantly different between group B1 (HES LRR) and group B2 (7.5% hypertonic saline HS). There was no significant difference among the three groups in fluid resuscitation at 24 hours. The contrast difference of group B _ 1 and B _ 2 was also significant (P 0.05). At 6 months follow-up, the GOS score showed that the fluid resuscitation group was better than the positive fluid resuscitation group. Conclusion: both positive fluid resuscitation and restrictive fluid resuscitation can effectively improve the state of shock in patients with moderate and severe craniocerebral injury complicated with hemorrhagic shock of multiple injuries. In terms of the rate of progression of intracranial hemorrhage and the incidence of ARDS mods and the GOS score at 6 months after injury, restrictive fluid resuscitation was more beneficial to the patients. However, the use of 7.5%HS during restricted fluid resuscitation can reduce the volume of fluid infusion, and may prevent the adverse effects on the body's environment in the early stage of shock.
【學(xué)位授予單位】：天津醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R651.15

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