【作者】 陆远强；

【导师】 蔡秀军；

【作者基本信息】 浙江大学 ， 外科学（普外）， 2001， 硕士

【摘要】 失血性休克是创伤早期最常见的死亡原因之一，以全身微循环灌流量急剧锐减，细胞普遍缺氧和重要器官遭受损害为特征的一种病理过程，即微循环衰竭导致线粒体氧供受损，也是细胞水平的一种急性营养代谢障碍。在彻底控制出血前快速大量输注液体（主要是晶体液），尽可能地将血压恢复到正常水平，一直是失血性休克的早期救治原则；近几年来，随着对失血性休克病理生理过程的深入研究，一系列动物实验和临床观察发现快速大量输液可能会严重扰乱机体对失血的代偿机制，并加速机体内环境的恶化。为此，不少学者提出在失血性休克早期进行限制性液体复苏的概念。 限制性液体复苏亦称低血压性液体复苏或延迟液体复苏，是指机体处于有活动性出血的失血性休克时，通过控制液体输注的速度，使机体血压维持在一个较低水平的血压范围内，直至手术彻底止血；其目标是寻求一个复苏平衡点，在此既可通过液体复苏适当地恢复组织器官的血流灌注，又不至于过多地扰乱机体的代偿机制和内环境。 本研究将通过比较无液体复苏、限制性液体复苏和快速大量液体复苏等三种复苏方式对重度失血性休克大鼠的复苏效果，以此来系统地评价早期限制性液体输注对失血性休克的复苏价值。 材料与方法 本实验采用Capone等设计的一种有活动性出血的SD大鼠失血性休克模型，根据不同的复苏方式分为空白组、对照组（无液体复苏组）、NS40组（限制性液体复苏组）和NS80组（快速大量液体复苏组），通过监测院前期（液体复苏期）的早期存活率、失血量、血小板计数、血红蛋白含量、血球比积、血清乳酸水平等变化情况以及应用光镜观察、TUNEL法和流式细胞仪等方法测定各组存活者的肝、肾、肺和小肠粘膜层等组织细胞的凋亡情况，比较上述三种液体复苏方式对大鼠失血性休克的复苏效果。 结 果 1儿制性液体复苏组（NS40组）和快速大量液体复苏组（NS80组）大鼠早期死亡率均比对照组（无液体复苏组）明显降低，因而，对重度失血性休克大鼠进行早期液体复苏是适宜的。 L 限制性液体复苏（NS40组）较快速大量液体复苏（NS80组）可显著减少切尾造成的继发出血量（P＜0刀 1），而与对照组相 2仿：同时，肥SO组的血红蛋白含量、血球比积和血小板计数在院前期均迅速下降，与对照组和NS狈组相比有统计学差异（P功刀1）；这说明：与快速大量液体复苏（NS80组）相比，限制性液体复苏 （NS40组）可防止血液过度稀释和凝血功能过度下降，减少出血量。 3、在院前期 60分钟及 90分钟时相点，限制性液体复苏（NS40组）和快速大量液体复苏（NS80组）的血清乳酸水平较对照组显著下降（P＜0刀1），这说明与对照组（无液体复苏组）相比较，限制性液体复苏（NS40组）及快速大量液体复苏（NS80组）均能有效地改善休克期组织脏器的灌注和氧供，减轻酸中毒。 4、三组大鼠中存活者的肝、肺、肾和小肠粘膜层等脏器均有不同程度的凋亡发生，其中以小肠粘膜层细胞最为显著。 5、快速大量液体复苏组（NS80组）大鼠的肝／肾和小肠粘膜层等脏器的凋亡细胞明显较限制性液体复苏组（NS40组）和对照组（无液体复苏组）为多，而在肺组织，三组大鼠的凋亡情况未见明显差别。这些说明：限制性液体复苏（NS40组）较快速大量液体复苏（NS80组）能减少肝、肾和小肠粘膜层等脏器细胞的凋亡，可能有助于减少复苏后各种并发症的发生而改善预后。 8＆ 有活动性出血的重度失血性休克大鼠模型中，限制性液体复苏（M＾P40 mmHg）较于无液体复苏和快速大量液体复苏（MAP80mmHg人 可明显改善大鼠预后。更多还原

【Abstract】 Hemorrhagic shock is the most common cause of death in the early stage of trauma patients, it’s physiopathologic characteristic is failure of the microcirculatory system that results in inadequate organ perfusion and tissue oxygenation. The guideline of early treatment of hemorrhagic shock is rapidly large fluid infusion (chiefly isotonic electrolyte solution) in order to increase the blood pressure to normal level before the bleeding-controlled operation. In recent years, along with further research of physiopathologic process of hemorrhagic shock, a series of animal experiments and clinical observations have showed that rapidly large fluid infusion may seriously disturb the compensatory mechanisms to hemorrhage and accelerate the deterioration of internal environment of trauma patients. So, some researchers have put forward the concept of controlled fluid resuscitation in early stage of hemorrhagic shock..5Controlled fluid resuscitation, also called hypotensive resuscitation or delayed fluid resuscitation, is referred to control the rate of fluid infusion in the situation of hemorrhagic shock with active bleeding, in order to maintain lower blood pressure of the organism than normal, till complete bleeding-control by procedure. The concept is to restore some intravascular fluid and tissue perfusion with fluid infusion while respecting compensatory mechanisms and internal environment.This study compares the curative effects of no fluid resuscitation controlled fluid resuscitation and rapidly large fluid resuscitation in rats of severe hemorrhagic shock, and systematically evaluate the resuscitative value of controlled fluid resuscitation.Materials and MethodsThe experiment used a model of SD rat with severe hemorrhagic shock and active bleeding, which was designed by Capone. Thirty-two SD rats fulfilling the criteria were divided into four groups named by the fluid resuscitation way. The four groups were the blank group control (no fluid resuscitation) groups NS4O (controlled fluid resuscitation) group and NS8O (rapidly large fluid resuscitation) group. We monitored the changes of survival blood loss blood platelet(PLT) hemoglobin(HB) hematocrit (HCT) and serum lactate in the prehospital phase. At the same time, optical micro scope TdT-mediated dUTP nick end labeling (TUNEL) and flow cytometry (FCM) were applied to detect the apoptosis of livers kidney.. lung and mucous layer of small intestine of all the survivals. Via above6mentioned indexes, we compared the curative effects of three fluid resuscitation ways in rats with severe hemorrhagic shock.Results1. All fluid-treated groups showed significantly better survival (p<O.O5) than the control group. Thus, it was suitable to infuse fluid early in rats with severe hemorrhagic shock.2 Blood loss secondary to tail-cut of the NS8O group was obviously higher (p<0.0 1) than that of the NS4O group, which was similar with the control group. At the same time, HB. HCT and PLT of the NS8O group was quickly descending in the prehospital phase, and showed statistically differences with the control and NS4O groups. It demonstrated that compared with rapidly large fluid resuscitation, controlled fluid resuscitation could decrease blood loss and avoid hemodilution and coagulopahty.3 At the 60-minute point and 90-minute point of the prehospital phase, serum lactate of the NS8O and NS4O groups remained lower than the control group (p<O.O 1). It showed that compared with no fluid resuscitation, controlled fluid resuscitation and rapidly large fluid resuscitation could effectively improve the perfusion and oxygen-delivery of tissues and lighten acidosis.4, There were some apoptosis in liver, lung kidney and mucous layer of small intestine of all survivals, especially in the mucous layer of small intestine.5 The NS8O group had more apoptosis cells in liver kidney and7mucous layer of small intestine than the control and NS4O groups. It showed that controlled fluid re更多还原