Objective: To investigate the application of pulse contour cardiac output (PiCCO) monitoring technology in fluid resuscitation of severe burn patients in shock period. Methods: From January 2015 to December 2019, 33 patients with severe burns who were hospitalized in Guangzhou Red Cross Hospital, meeting the inclusion criteria, were recruited into a retrospective cohort study with their clinical information collected. The patients were divided into PiCCO monitoring group with 15 cases (13 males and 2 females, aged (43±13) years) and routine monitoring group with 18 cases (14 males and 4 females, aged (39±9) years) according to the monitoring method used. After admission, all the patients were rehydrated following the rehydration formula of the Third Military Medical University for shock period. In routine monitoring group, the fluid resuscitation of patients was performed by monitoring indicators such as urine volume and blood pressure, while PiCCO monitoring was performed among patients in PiCCO monitoring group, and their fluid resuscitation was guided by the patient's condition and the hemodynamic parameters (without pursuing normal levels of the parameters) of PiCCO monitoring on the basis of normal monitoring indicators in routine monitoring group. The colloids coefficients, the electrolyte coefficients (compared with the corresponding rehydration formula value of 0.75 mL·kg(-1)·% total body surface area (TBSA)(-1) of the Third Military Medical University for shock period during the first 24 h post injury), the total rehydration coefficients, and the urine volumes during the first and second 24 h post injury, the lactic acid level, the base excess level, and the oxygenation index at admission and 24, 48 h after admission, and the mechanical ventilation time, the wound healing time, and the death ratio of patients in the two groups were recorded. The cardiac index, the global end-diastolic volume index (GEDVI), the intrathoracic blood volume index (ITBVI), the extravascular lung water index (EVLWI), and the systemic vascular resistance index (SVRI) of patients in PiCCO monitoring group at post injury hour 24, 48, and 72 and the abnormal cases were recorded. Data were statistically analyzed with Fisher's exact probability test, independent-sample or one-sample t test, analysis of variance for repeated measurement, and Bonferroni correction. Results: During the first 24 h post injury, the colloids coefficients of patients in PiCCO monitoring group was (0.69±0.15) mL·kg(-1)·%TBSA(-1), which was significantly less than (0.85±0.16) mL·kg(-1)·%TBSA(-1) in routine monitoring group (t=-2.612, P<0.05). Compared with the rehydration formula value of the Third Military Medical University for shock period, only the colloids coefficient of patients in routine monitoring group during the first 24 h post injury was significantly increased (t=2.847, P<0.05). There were no statistically significant differences between the two groups in the colloids coefficients of patients during the second 24 h post injury, or the electrolyte coefficients, the total rehydration coefficients, the urine volumes of patients during the first and the second 24 h post injury (t=0.579, -0.011, 0.417, -1.321, -0.137, 0.031, 1.348, P>0.05). The lactic acid level, the base excess level, the oxygenation index of patients at admission and 48 h after admission, and the oxygenation index of patients at 24 h after admission between the two groups were similar (t=-1.837, 0.620, 0.292, -1.792, 1.912, -0.167, 1.695, P>0.05). The levels of lactic acid and base excess of patients in PiCCO monitoring group were (4.8±1.4) and (1.2±5.5)mmol/L, respectively, which were significantly better than (7.0±1.5) and (-2.8±3.0) mmol/L in routine monitoring group at 24 h after admission (t=-3.904, 2.562, P<0.05 or P<0.01). There were no statistically significant differences between the two groups in the mechanical ventilation time or the wound healing time of patients (t=-0.699, -0.697, P>0.05), or the death ratio of patients (P>0.05). In PiCCO monitoring group, the GEDVI, and the ITBVI of patients were lower than the normal low values at post injury hour 24 and 48, which were in the normal range at post injury hour 72; the cardiac index of patients increased gradually and recovered to normal at post injury hour 48; the SVRI of patients increased significantly at post injury hour 24 and then gradually decreased to normal; the EVLWI average of patients at all time points post injury were less than 10 mL/kg. At post injury hour 24, most of the hemodynamic parameters of more than or equal to 8/15 patients in PiCCO monitoring group were abnormal, and the abnormal proportion decreased later. Conclusions: On the basis of traditional monitoring indicators, the use of PiCCO monitoring technology combined with the patient's condition (without pursuing normal levels of the parameters) in guiding the fluid resuscitation in severe burn patients can reduce the usage of colloid and better improve tissue perfusion, with the resuscitation effect being better than conventional monitoring.
目的： 探讨脉搏轮廓心输出量(PiCCO)监测技术在严重烧伤患者休克期液体复苏中的应用。 方法： 2015年1月—2019年12月，广州市红十字会医院收治的33例严重烧伤患者符合入选标准，收集其临床资料进行回顾性队列研究。根据采用的监测方法，将患者分为PiCCO监测组15例[男13例、女2例，年龄(43±13)岁]与常规监测组18例[男14例、女4例，年龄(39±9)岁]。患者入院后均按照第三军医大学休克期补液公式进行补液，常规监测组通过监测患者尿量、血压等指标进行液体复苏；PiCCO监测组患者行PiCCO监测，在常规监测组监测指标的基础上，综合患者情况及PiCCO监测的血流动力学参数(不追求参数达到正常水平)指导液体复苏。统计2组患者伤后第1、2个24 h的胶体系数与电解质系数[同时将伤后第1个24 h胶体系数、电解质系数与第三军医大学休克期补液公式值0.75 mL·kg(-1)·%体表总面积(TBSA)(-1)比较]、总补液系数、尿量，入院时及入院后24、48 h乳酸、碱剩余水平及氧合指数，机械通气时间、创面愈合时间、病死比例；统计PiCCO监测组患者伤后24、48、72 h心脏指数、全心舒张末期容积指数(GEDVI)、胸腔内血容量指数(ITBVI)、血管外肺水指数(EVLWI)、外周血管阻力指数(SVRI)水平以及这些指标异常的病例数。对数据行Fisher确切概率法检验、独立样本或单样本t检验、重复测量方差分析、Bonferroni校正。 结果： PiCCO监测组患者伤后第1个24 h的胶体系数为(0.69±0.15)mL·kg(-1)·%TBSA(-1)，明显少于常规监测组的(0.85±0.16)mL·kg(-1)·%TBSA(-1)(t＝-2.612，P<0.05)；与第三军医大学休克期补液公式值比较，仅常规监测组患者伤后第1个24 h胶体系数明显增多(t＝2.847，P<0.05)。2组患者伤后第2个24 h胶体系数及伤后第1、2个24 h电解质系数、总补液系数、尿量相近(t＝0.579，-0.011、0.417，-1.321、-0.137，0.031、1.348，P>0.05)。2组患者入院时与入院后48 h乳酸水平、碱剩余水平、氧合指数及入院后24 h氧合指数相近(t＝-1.837、0.620、0.292，-1.792、1.912、-0.167，1.695，P>0.05)。PiCCO监测组患者入院后24 h乳酸及碱剩余水平分别为(4.8±1.4)、(1.2±5.5)mmol/L，明显优于常规监测组的(7.0±1.5)、(-2.8±3.0)mmol/L(t＝-3.904、2.562，P<0.05或P<0.01)。2组患者机械通气时间、创面愈合时间相近(t＝-0.699、-0.697，P>0.05)，病死比例相近(P>0.05)。PiCCO监测组患者GEDVI和ITBVI在伤后24、48 h低于正常值低值，在伤后72 h处于正常值范围；心脏指数逐渐升高，于伤后48 h恢复正常；SVRI在伤后24 h显著升高后逐渐下降至正常；EVLWI均数在伤后各时间点均<10 mL/kg。伤后24 h，PiCCO监测组≥8/15的患者大部分血流动力学参数异常，之后异常比例有所下降。 结论： 在常规监测指标的基础上，采用PiCCO监测技术结合患者综合情况，不以血流动力学参数正常为目标指导严重烧伤患者液体复苏，可减少胶体的使用量，更好地改善组织灌注，复苏效果优于常规监测。.
Keywords: Burns; Fluid therapy; Hemodynamics; Pulse contour cardiac output monitoring; Shock.