骨髓腔内通路在成人创伤失血性休克患者急救中的应用

doi:10.3877/cma.j.issn.2095-9133.2021.03.003

目的

比较静脉通路和骨髓腔内通路在创伤失血性休克患者急救中的应用效果。

方法

选取2017年11月至2019年5月在常州市第二人民医院急诊抢救室救治的创伤失血性休克患者60例，其中男性48例，女性12例，年龄(45.6±15.2)岁。30例接受静脉通路治疗，30例接受骨髓腔内通路治疗，记录两组建立输液通路第一次穿刺成功率和穿刺时间。穿刺成功后均予以300 mmHg加压输入30 mL·kg^-1乳酸林格氏液，记录两组输液时间、输液前(T₀)和输液后10 min内每分钟(T_1-10)的收缩压(SBP)、舒张压(DBP)和平均动脉压(MAP)。

结果

两组患者性别、年龄、体质指数(BMI)和T₀时MAP组间差异无统计学意义。与静脉通路组比较，骨髓腔内通路组输液时间缩短，输液速度提高(P<0.05)。与T₀时比较，两组T_1-10时SBP、DBP和MAP升高(P<0.05)；与静脉通路组比较，骨髓腔内通路组第一次穿刺成功率提高，穿刺时间缩短(P<0.05)；T_1-10时SBP、DBP和MAP升高(P<0.05)。

结论

骨髓腔内通路用于成人创伤失血性休克患者的治疗效果优于静脉通路。

关键词: 骨髓腔内通路, 静脉通路, 创伤失血性休克

Objective

To compare the application effect of venous access and intracavitary access in emergency treatment of patients with traumatic hemorrhagic shock.

Methods

From November 2017 to may 2019, 60 patients with traumatic hemorrhagic shock were selected, including 48 males and 12 females, aged (45.6±15.2) years. 30 cases received intravenous access treatment, 30 cases received intracerebral access treatment. The first puncture success rate and puncture time of two groups were recorded. The infusion time, SBP, DBP and map were recorded before infusion (T₀) and 10 minutes after infusion (T_1-10).

Results

There were no significant differences in gender, age, body mass index (BMI) and map at T₀ between the two groups. Compared with the venous access group, the infusion time was shorter and the infusion speed was higher in the intramedullary access group (P<0.05). Compared with T₀, SBP, DBP and map increased at T_1-10 (P<0.05); Compared with the venous access group, the success rate of the first puncture was higher and the puncture time was shorter in the Endomedullary access group (P<0.05); SBP, DBP and map increased at T_1-10 (P<0.05).

Conclusions

The therapeutic effect of intracavitary access in adult patients with traumatic hemorrhagic shock is better than that of intravenous access.

Key words: intraosseous vascular access, intravenous transfusion, hemorrhagic shock

表1 两组患者穿刺时间和输液时间比较(±s)

组别	例数	性别(男/女)	年龄(岁)	BMI(kg/m²)	穿刺时间(s)	输液时间(min)	输液速度(mL/min)
Ⅳ组	30	23/7	45.8±17.0	23.0±3.1	128.8±68.2	34.6±2.5	39.6±4.2
IO组	30	25/5	45.3±13.4	23.7±3.5	86.2±15.1	12.5±1.8	148.9±10.1
t值			-0.13	0.67	-51.01	-21.58	203.70
P值		>0.05	>0.05	>0.05	<0.05	<0.05	<0.05

表1 两组患者穿刺时间和输液时间比较(±s)

组别	例数	性别(男/女)	年龄(岁)	BMI(kg/m²)	穿刺时间(s)	输液时间(min)	输液速度(mL/min)
Ⅳ组	30	23/7	45.8±17.0	23.0±3.1	128.8±68.2	34.6±2.5	39.6±4.2
IO组	30	25/5	45.3±13.4	23.7±3.5	86.2±15.1	12.5±1.8	148.9±10.1
t值			-0.13	0.67	-51.01	-21.58	203.70
P值		>0.05	>0.05	>0.05	<0.05	<0.05	<0.05

表2 两组患者第一次穿刺成功率的比较

组别	例数	第一次穿刺成功例数	第一次穿刺失败例数	穿刺成功率(%)
Ⅳ组	30	19	11	63.3
IO组	30	27	3	90.0
χ²值				5.96
P值				<0.05

表2 两组患者第一次穿刺成功率的比较

组别	例数	第一次穿刺成功例数	第一次穿刺失败例数	穿刺成功率(%)
Ⅳ组	30	19	11	63.3
IO组	30	27	3	90.0
χ²值				5.96
P值				<0.05

表3 两组各时点血流动力学指标比较(±s)

组别	例数	SBP(mmHg)
组别	例数	T₀	T₁	T₂	T₃	T₄	T₅	T₆	T₇	T₈	T₉	T₁₀
Ⅳ组	30	84.7±6.4	90.2±6.2^a	93.4±5.8^a	98.9±5.4^a	104.5±5.4^a	108.8±5.3^a	111.3±4.9^a	113.7±4.8^a	116.2±4.7^a	118.3±4.5^a	120.7±4.3^a
IO组	30	85.5±7.1	94.2±6.0^a	98.7±5.2^a	103.4±4.0^a	113.5±3.7^a	118.2±3.5^a	120.9±3.5^a	123.2±3.6^a	125.3±3.9^a	127.6±4.3^a	129.8±4.3^a
t值		0.46	2.57	3.73	3.61	7.58	8.07	8.68	8.77	8.17	8.11	8.13
P值		>0.05	<0.05	<0.05	<0.05	<0.05	<0.05	<0.05	<0.05	<0.05	<0.05	<0.05
组别	例数	DBP(mmHg)
组别	例数	T₀	T₁	T₂	T₃	T₄	T₅	T₆	T₇	T₈	T₉	T₁₀
Ⅳ组	30	42.9±5.7	45.3±4.6^a	48.4±4.5^a	50.4±4.5^a	50.9±4.1^a	51.6±3.7^a	53.1±3.4^a	53.4±3.3^a	55.5±3.1^a	56.8±3.0^a	59.0±2.8^a
IO组	30	42.8±4.9	48.3±5.5^a	53.4±5.5^a	57.4±5.3^a	58.5±4.8^a	60.3±4.6^a	61.3±4.2^a	62.4±3.5^a	63.0±3.0^a	64.4±3.0^a	64.7±2.8^a
t值		0.07	2.34	3.83	5.50	6.57	8.05	8.25	10.26	9.55	9.93	7.96
P值		>0.05	<0.05	<0.05	<0.05	<0.05	<0.05	<0.05	<0.05	<0.05	<0.05^a	<0.05
组别	例数	MAP(mmHg)
组别	例数	T₀	T₁	T₂	T₃	T₄	T₅	T₆	T₇	T₈	T₉	T₁₀
Ⅳ组	30	57.4±5.6	59.8±4.9^a	61.3±4.9^a	62.4±4.8a	63.6±4.8^a	64.6±4.8^a	65.8±4.8^a	66.9±4.9^a	68.0±4.9^a	69.0±4.9^a	70.2±4.9^a
IO组	30	56.7±4.9	64.1±5.8^a	68.3±5.7^a	71.4±5.6^a	75.2±5.9^a	78.1±5.5^a	80.3±4.9^a	82.2±4.5^a	83.9±3.7^a	85.8±2.6^a	87.4±2.0^a
t值		0.51	3.08	5.10	6.68	8.36	10.11	11.62	12.64	14.21	16.43	17.94
P值		>0.05	<0.05	<0.05	<0.05	<0.05	<0.05	<0.05	<0.05	<0.05	<0.05	<0.05

表3 两组各时点血流动力学指标比较(±s)

组别	例数	SBP(mmHg)
组别	例数	T₀	T₁	T₂	T₃	T₄	T₅	T₆	T₇	T₈	T₉	T₁₀
Ⅳ组	30	84.7±6.4	90.2±6.2^a	93.4±5.8^a	98.9±5.4^a	104.5±5.4^a	108.8±5.3^a	111.3±4.9^a	113.7±4.8^a	116.2±4.7^a	118.3±4.5^a	120.7±4.3^a
IO组	30	85.5±7.1	94.2±6.0^a	98.7±5.2^a	103.4±4.0^a	113.5±3.7^a	118.2±3.5^a	120.9±3.5^a	123.2±3.6^a	125.3±3.9^a	127.6±4.3^a	129.8±4.3^a
t值		0.46	2.57	3.73	3.61	7.58	8.07	8.68	8.77	8.17	8.11	8.13
P值		>0.05	<0.05	<0.05	<0.05	<0.05	<0.05	<0.05	<0.05	<0.05	<0.05	<0.05
组别	例数	DBP(mmHg)
组别	例数	T₀	T₁	T₂	T₃	T₄	T₅	T₆	T₇	T₈	T₉	T₁₀
Ⅳ组	30	42.9±5.7	45.3±4.6^a	48.4±4.5^a	50.4±4.5^a	50.9±4.1^a	51.6±3.7^a	53.1±3.4^a	53.4±3.3^a	55.5±3.1^a	56.8±3.0^a	59.0±2.8^a
IO组	30	42.8±4.9	48.3±5.5^a	53.4±5.5^a	57.4±5.3^a	58.5±4.8^a	60.3±4.6^a	61.3±4.2^a	62.4±3.5^a	63.0±3.0^a	64.4±3.0^a	64.7±2.8^a
t值		0.07	2.34	3.83	5.50	6.57	8.05	8.25	10.26	9.55	9.93	7.96
P值		>0.05	<0.05	<0.05	<0.05	<0.05	<0.05	<0.05	<0.05	<0.05	<0.05^a	<0.05
组别	例数	MAP(mmHg)
组别	例数	T₀	T₁	T₂	T₃	T₄	T₅	T₆	T₇	T₈	T₉	T₁₀
Ⅳ组	30	57.4±5.6	59.8±4.9^a	61.3±4.9^a	62.4±4.8a	63.6±4.8^a	64.6±4.8^a	65.8±4.8^a	66.9±4.9^a	68.0±4.9^a	69.0±4.9^a	70.2±4.9^a
IO组	30	56.7±4.9	64.1±5.8^a	68.3±5.7^a	71.4±5.6^a	75.2±5.9^a	78.1±5.5^a	80.3±4.9^a	82.2±4.5^a	83.9±3.7^a	85.8±2.6^a	87.4±2.0^a
t值		0.51	3.08	5.10	6.68	8.36	10.11	11.62	12.64	14.21	16.43	17.94
P值		>0.05	<0.05	<0.05	<0.05	<0.05	<0.05	<0.05	<0.05	<0.05	<0.05	<0.05

1	栾樱译，姚咏明．创伤失血性休克诊治中的病理生理机制[J]．中华急诊医学杂志，2018，27(11)：1189-1191.
2	汪宇鹏，刘艳艳．中国骨髓腔内输液通路临床应用专家共识[J]．中国急救医学，2019，39(7)：620-624.
3	Costantino TG, Kirtz JF, Satz WA.Ultrasound-guided peripheral venous access vs. The external jugular vein as the initial approach to the patient with difficult vascular access[J]. J Emerg Med, 2010, 39(4): 462-467.
4	Oliver LA, Oliver JA, Ohanyan S, et al.Ultrasound for peripheral and arterial access[J]. Best Pract Res Clin Anaesthesiol, 2019, 33(4): 523-537.
5	Prottengeier J, Albermann M, Heinrich S, et al.The prehospital intravenous access assessment: a prospective study on intravenous access failure and access delay in prehospital emergency medicine[J]. Eur J Emerg Med, 2016, 23(6): 442-447.
6	Paxton JH, Knuth TE, Klausner HA.Proximal humerus intraosseous infusion: a preferred emergency venous access[J]. J Trauma, 2009, 67(3): 606-611.
7	Leidel BA, Kirchhoff C, Bogner V, et al.Is the intraosseous route fast and efficacious compared to conventional central venous catheterisation in adult patients under resuscitation in the emergency department? A prospective observational pilot study[J]. Patient Saf Surg, 2009, 3(1): 24.
8	Franco-Sadud R, Schnobrich D, Mathews BK, et al.Recommendations on the Use of ultrasound guidance for central and peripheral vascular access in adults: a position statement of the society of hospital medicine[J]. J Hosp Med, 2019, 6(14): E1-E22.
9	Kurowski A, Timler D, Ecrin T, et al.Comparison of 3 different intraosseous access devices for adult during resuscitation.Randomized crossover manikin study[J]. Am J Emerg Med, 2014, 32(12): 1490-1493.
10	Lee PM, Lee C, Rattner P, et al.Intraosseous versus central venous catheter utilization and performance during inpatient medical emergencies[J]. Crit Care Med, 2015, 43(6): 1233-1238.
11	Comerlato PH, Rebelatto TF, Santiago de Almeida FA, et al.Complications of central venous catheter insertion in a teaching hospital[J]. Rev Assoc Med Bras, 2017, 63(7): 613-620.
12	刘艳艳，汪宇鹏，祖凌云，等．危重症患者建立骨髓腔内通路和中心静脉通路随机对照研究[J]．中华急诊医学杂志，2018，27(8)：901-904.
13	Johnson D, Giles K, Acuna A, et al.Effects of tibial intraosseous and IV administration of vasopressin on kinetics and survivability in cardiac arrest[J]. Am J Emerg Med, 2016, 34(3): 429-432.

[1]	潘鑫, 王鹏, 花长松, 何斌, 陈伟, 李政. 抗休克服在院前创伤失血性休克急救中的应用[J]. 中华卫生应急电子杂志, 2019, 05(02): 100-103.

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Application of intraosseous access in adult patients with hemorrhagic shock

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Application of intraosseous access in adult patients with hemorrhagic shock