高明娟,李　娟,王曉娜,胡　森,盛志勇,張慧萍,白曉東

?

50%TBSA Ⅲ度燒傷犬靜脈補(bǔ)液時(shí)丙酮酸鈉林格液對(duì)循環(huán)血容量和血乳酸水平的影響

高明娟1,李娟1,王曉娜1,胡森2,盛志勇2,張慧萍2,白曉東1

目的研究燒傷犬靜脈補(bǔ)液時(shí)丙酮酸鈉林格液對(duì)循環(huán)血容量和血乳酸水平的影響。方法采用雄性Beagle犬，預(yù)先施行頸總動(dòng)脈和頸外靜脈置管，24 h后用凝固汽油燃燒法制成犬50%總體表面積(TBSA)Ⅲ度燒傷模型。將犬隨機(jī)分為3組：不補(bǔ)液組(NR組，n=8)、乳酸鈉林格液靜脈補(bǔ)液組(VL組，n=10)和丙酮酸鈉林格液靜脈補(bǔ)液組(VP組，n=10)。兩靜脈補(bǔ)液組于傷后30 min依據(jù)Parkland公式經(jīng)頸靜脈分別輸注丙酮酸鈉林格液或乳酸鈉林格液。動(dòng)物在清醒狀態(tài)下測(cè)定平均動(dòng)脈壓、循環(huán)血漿容量、動(dòng)脈血?dú)夂脱樗崴?。結(jié)果傷后2 h，NR組、VL組和VP組動(dòng)物平均動(dòng)脈壓分別為(45.3±7.8)、(91.3±10.2)和(98.7±9.5)mmHg，較傷前值(141.7±6.0)、(142.3±6.1)和(142.8±5.5)mmHg明顯降低(P均<0.05)；循環(huán)血漿容量、動(dòng)脈pH值和PaO2變化趨勢(shì)與平均動(dòng)脈壓相似，但血乳酸濃度較傷前明顯降低(P<0.05)。傷后4 h起NR組各項(xiàng)指標(biāo)均持續(xù)惡化，直至死亡；而靜脈補(bǔ)液組各指標(biāo)逐漸恢復(fù)。兩靜脈補(bǔ)液組比較，VP組優(yōu)于VL組，在燒傷補(bǔ)液后6 h差別尤為明顯(P均<0.05)。結(jié)論50%TBSA Ⅲ度燒傷犬靜脈補(bǔ)液時(shí)，丙酮酸鈉林格液改善循環(huán)血容量和乳酸性酸中毒的效果優(yōu)于常用的乳酸林格液。

燒傷；休克；靜脈補(bǔ)液；丙酮酸鹽；循環(huán)血容量；乳酸性酸中毒

嚴(yán)重戰(zhàn)、創(chuàng)(燒)傷能導(dǎo)致循環(huán)血容量銳減、臟器組織灌注急劇減少，進(jìn)而組織缺氧、細(xì)胞代謝障礙，各種炎性因子釋放，發(fā)生缺氧型乳酸性酸中毒[1]。燒傷休克早期救治最有效的方法是進(jìn)行充分的液體復(fù)蘇，液體復(fù)蘇實(shí)施的越早，燒傷休克早期病死率就越低。液體復(fù)蘇的方式有很多種，如靜脈補(bǔ)液、口服補(bǔ)液、胃內(nèi)灌注補(bǔ)液等，其中靜脈補(bǔ)液是最主要最重要的方式。休克期液體復(fù)蘇的目的不是單純提升血壓，而在于改善全身組織血流灌注量，恢復(fù)并維護(hù)細(xì)胞正常代謝和臟器功能[2]，因此選擇一種可快速抗休克、明顯改善全身臟器炎性反應(yīng)，并且不良反應(yīng)極少的晶體液十分必要。大量實(shí)驗(yàn)證明，丙酮酸在休克和重要器官損傷方面有治療作用，對(duì)燒傷低血容量性休克的動(dòng)物器官功能起保護(hù)作用，可提高生存率[3-6]。本實(shí)驗(yàn)的目的是觀察50%TBSA Ⅲ度燒傷犬靜脈補(bǔ)液時(shí)丙酮酸鈉林格液對(duì)循環(huán)血容量和血乳酸水平的影響，為臨床治療Ⅲ度燒傷提供實(shí)驗(yàn)依據(jù)。

1　材料與方法

1.1動(dòng)物模型建立和分組成年雄性Beagle犬(軍事醫(yī)學(xué)科學(xué)院動(dòng)物研究所)，體重為9.5～10.5 kg。實(shí)驗(yàn)前24 h禁食，4 h禁飲。采用胡森等[3]的方法，氯胺酮(8 mg/kg)+速眠新Ⅱ(0.4 mg)肌注麻醉，進(jìn)行無(wú)菌置管術(shù)，頸總動(dòng)脈切開(kāi)置入心肺容量監(jiān)護(hù)儀(picco-PLUS, 德國(guó)PULSION公司)的壓力/溫度感應(yīng)導(dǎo)管，監(jiān)測(cè)血流動(dòng)力學(xué)指標(biāo)，頸外靜脈置入靜脈留置管。術(shù)后24 h動(dòng)物清醒，先經(jīng)頸外靜脈注射1%丙泊酚0.5 ml/kg進(jìn)行10～15 min短效麻醉，在其頸背部、臀部和腹部均勻涂抹適量3%凝固汽油，燃燒30 s造成Ⅲ度燒傷，采用貼紙法計(jì)算致傷區(qū)域總面積約(50.4±3.2%)%總體表面積(TBSA)，組織病理學(xué)檢查驗(yàn)證燒傷深度。隨機(jī)數(shù)字表法分為：?jiǎn)渭儫齻M(NR組)8只，乳酸鈉林格液組(VL組)和丙酮酸鈉林格液組(VP組) ，每組10只。NR組燒傷傷后無(wú)治療，VP組和VL組于傷后30 min從頸靜脈內(nèi)開(kāi)始補(bǔ)液，補(bǔ)液量和補(bǔ)液速度均依據(jù)Parkland燒傷補(bǔ)液公式，即每1% TBSA補(bǔ)液4 ml/kg，傷后第1個(gè)8 h補(bǔ)50%，之后16 h補(bǔ)另50%。在動(dòng)物清醒狀態(tài)下，所有實(shí)驗(yàn)動(dòng)物于傷后0、2、6、8、12、24 h分別取動(dòng)靜脈血觀察動(dòng)脈血?dú)?、循環(huán)血容量和平均動(dòng)脈壓的變化。

1.2液體配方乳酸鈉林格液購(gòu)自中國(guó)大冢制藥有限公司，pH值6.5，室溫保存，丙酮酸鈉林格液有實(shí)驗(yàn)室配制，將等分子質(zhì)量的丙酮酸鈉(購(gòu)于美國(guó)Sigma公司)取代乳酸鈉林格液中的乳酸鈉而成，pH值6.2；濾過(guò)消毒后4 ℃冰箱保存，使用前置于恒溫水浴箱預(yù)熱至室溫25 ℃?zhèn)溆谩?/p>

1.3指標(biāo)觀測(cè)在動(dòng)物清醒狀態(tài)下，所有實(shí)驗(yàn)動(dòng)物于傷后0、2、6、8、12、24 h分別取動(dòng)靜脈血觀察動(dòng)脈血?dú)?、循環(huán)血容量和平均動(dòng)脈壓的變化。動(dòng)脈血?dú)獠捎萌詣?dòng)血?dú)夥治鰞x測(cè)定；采用心肺容量監(jiān)護(hù)儀(Picco-PLUS, 德國(guó)PULSION公司)監(jiān)測(cè)平均動(dòng)脈壓；循環(huán)血漿容量采用靛青綠染料稀釋法測(cè)定[7]。

2　結(jié)　　果

2.1平均動(dòng)脈壓及循環(huán)血漿容量的變化3組犬燒傷后，平均動(dòng)脈壓及循環(huán)血漿容量與燒傷前比較，均顯著降低；NR組平均動(dòng)脈壓及循環(huán)血漿容量持續(xù)降低，直至死亡。兩靜脈補(bǔ)液組補(bǔ)液后平均動(dòng)脈壓及循環(huán)血漿容量緩慢回升，均高于NR組(P<0.05)，但VP組高于VL組(P<0.05，表1)。

表1　50%TBSA燒傷犬平均動(dòng)脈壓及循環(huán)血漿容量的變化　±s)

注：NR、VL、VP分別表示單純燙傷組、乳酸鈉林格液、丙酮酸鈉林格液；與NR組比較，①P<0.05；與VL組比較， ②P<0.05；“-”：NR組24 h內(nèi)全部死亡，無(wú)數(shù)據(jù)

2.2血乳酸濃度、pH值及PaO2變化3組犬燒傷后，動(dòng)脈pH值和PaO2比傷前顯著降低，血乳酸水平顯著升高；NR組傷后pH值和PaO2持續(xù)降低，血乳酸濃度持續(xù)升高，直至死亡；VL組和VP組傷后pH值、PaO2逐漸恢復(fù)，顯著高于NR組(P均<0.05)，VL組和VP組血乳酸水平緩慢降低、接近正常水平；VP組動(dòng)脈pH值和PaO2顯著高于VL組(均P<0.05)，血乳酸水平低于VL組(P<0.05, 表2)。

組別例數(shù)燒傷后時(shí)間(h)02681224血乳酸濃度(mmol/L) NR81.62±0.298.50±0.3111.00±0.4511.70±0.5111.70±0.31- VL101.73±0.266.40±0.39①6.00±0.39①5.60±0.32①5.60±0.32①5.40±0.24 VP101.75±0.245.60±0.23①4.92±0.44①3.20±0.39①②3.20±0.39①②2.60±0.36②pH值 NR87.40±0.036.95±0.026.95±0.076.98±0.107.0±0.07- VL107.39±0.027.18±0.017.30±0.07①7.28±0.08①7.33±0.02①7.36±0.09 VP107.41±0.027.22±0.06①②7.32±0.08①7.36±0.05①②7.39±0.03①②7.39±0.06PaO2(mmHg) NR8113.67±2.60 98.15±2.75 98.70±3.3385.92±3.2581.33±2.81- VL10113.58±3.29100.63±3.43①104.57±3.37①105.40±3.55①107.48±3.27①109.18±3.95 VP10112.59±2.63101.62±1.03①105.72±2.05①107.67±1.97①②109.62±1.23①②111.22±1.81②

注：NR、VL、VP分別表示單純燙傷組、乳酸林鈉格液、丙酮酸鈉林格液；PaO2動(dòng)脈氧分壓；與NR組比較，①P<0.05；與VL組比較，②P<0.05

3　討　　論

嚴(yán)重?zé)齻篌w液大量流失，組織循環(huán)血量不足，易發(fā)生低血容量休克，組織缺氧，糖的無(wú)氧代謝加強(qiáng)，乳酸等大量的酸根離子產(chǎn)生，發(fā)生高陰離子間隙性代酸[8]。同時(shí)，伴有大量炎性因子的釋放，如TNF、VEGF、PAF等，致使血管內(nèi)皮細(xì)胞損傷，組織液大量外滲，循環(huán)血量不足，進(jìn)一步加重低血容量休克。以往研究發(fā)現(xiàn)，傷后大量靜脈補(bǔ)液是治療燒傷休克的重要措施，燒傷復(fù)蘇常用的電解質(zhì)液為平衡鹽溶液和乳酸林格液，但輸入大量乳酸林格液會(huì)引起心、肺、腸水腫，并發(fā)ARDS[9]，還會(huì)引起嚴(yán)重的炎性反應(yīng)，促使多種細(xì)胞凋亡[10]。

近年來(lái)開(kāi)發(fā)的高滲氯化鈉、高晶高膠液、醋酸、丙酮酸等替代乳酸林格液的復(fù)蘇溶液，但其在燒傷復(fù)蘇中的作用還需進(jìn)一步研究。本實(shí)驗(yàn)發(fā)現(xiàn)輸入丙酮酸可達(dá)到快速有效改善休克，保護(hù)重要器官并改善酸中毒的效果。Flaherty等[4]通過(guò)對(duì)比丙酮酸林格液與乳酸林格液對(duì)失血性休克山羊的復(fù)蘇，證明丙酮酸林格液可以明顯改善山羊的血流動(dòng)力學(xué)，抑制心肌氧化應(yīng)激和炎性反應(yīng)。Su等[11]采用丙酮酸乙酯治療大動(dòng)物膿毒性休克模型，發(fā)現(xiàn)其可以降低心動(dòng)過(guò)速發(fā)生率，延遲低血壓和少尿的發(fā)生時(shí)間。Schillinger等[12]研究結(jié)果顯示，急性心肌梗死、心源性休克的患者，早期行經(jīng)皮冠脈介入治療以及主動(dòng)脈內(nèi)球囊反搏術(shù)后，經(jīng)冠脈運(yùn)用丙酮酸可明顯提高休克患者心指數(shù)、每搏心排血指數(shù)及平均收縮壓等血流動(dòng)力學(xué)指標(biāo)，同時(shí)患者心率沒(méi)有明顯改變。Ojha等[13]在用異丙腎上腺素誘導(dǎo)的心肌梗死大鼠模型的研究中顯示，丙酮酸可明顯減輕大鼠心肌氧化應(yīng)激損傷，改善心臟功能。以往的研究表明丙酮酸有抑制細(xì)胞凋亡、抗氧化、抗酸、抗炎等生理作用，在燒傷休克時(shí)能糾正酸中毒[14-16]。Mongan等[17，18 ]在豬的失血性休克模型中，丙酮酸鹽能有效地預(yù)防或糾正嚴(yán)重的乳酸性酸中毒；丙酮酸鹽在膿毒癥、燒傷、失血性休克、器官缺血再灌注損傷等急性危重疾病中具有糾正嚴(yán)重酸中毒, 抗氧化作用，抑制炎性因子和保護(hù)線粒體的功能[19-21]；靜脈輸入丙酮酸林格氏液能有效的糾正致死性失血性休克模型酸中毒和血液動(dòng)力學(xué)紊亂，延長(zhǎng)動(dòng)物的存活時(shí)間[22]。

本實(shí)驗(yàn)采用50% TBSA Ⅲ度燒傷犬模型，在燒傷后24 h內(nèi)靜脈補(bǔ)充丙酮酸鈉林格液和乳酸鈉林格液，觀察研究平均動(dòng)脈壓、循環(huán)血漿容量、動(dòng)脈血?dú)夂脱樗崴阶兓闆r。結(jié)果證實(shí)，嚴(yán)重?zé)齻笕难樗釢舛容^傷前均明顯升高，pH值、PaO2顯著降低，兩補(bǔ)液組較NR組血乳酸濃度、pH值、PaO2明顯改善，VP組較VL組效果更優(yōu)；循環(huán)血漿容量、平均動(dòng)脈壓比傷前明顯降低，兩補(bǔ)液組較NR組平均動(dòng)脈壓及循環(huán)血漿容量明顯恢復(fù)，VP組優(yōu)于VL組。結(jié)果表明，丙酮酸鈉林格液對(duì)重度燒傷休克動(dòng)物的乳酸性酸中毒和循環(huán)血漿容量的影響優(yōu)于傳統(tǒng)配方乳酸鈉林格液。

本實(shí)驗(yàn)不足之處：只觀察液體復(fù)蘇后循環(huán)血漿容量、平均動(dòng)脈壓、血乳酸水平，以及pH值的變化情況，未能同時(shí)觀察體內(nèi)酸堿離子、其他炎性因子及能量代謝關(guān)鍵酶活性，實(shí)驗(yàn)主要著眼于探討外源性丙酮酸鹽對(duì)乳酸性酸中毒及循環(huán)血量的影響，其他方面作用有待進(jìn)一步研究。

[1]Kraut J A, Kurtz I. Use of base in the treatment of severe acidemic states [J]. Am J Kidney Dis, 2001, 3(8): 703-727.

[2]郇京寧. 燒傷休克液體復(fù)蘇研究進(jìn)展[J]. 中華燒傷雜志, 2013, 29(3): 285-288.

[3]胡森, 夏斌, 黎君友, 等. 犬腸缺血-再灌流時(shí)小腸對(duì)早期胃內(nèi)營(yíng)養(yǎng)耐受能力的實(shí)驗(yàn)研究[J]. 中國(guó)危重病急救醫(yī)學(xué)，2006, 18(10): 605-608.

[4]Flaherty D C, Hoxha B, Sun J,etal. Pyruvate-fortified fluid resuscitation improves hemodynamic stability while suppressing systemic inflammation and myocardial oxidative stress after hemorrhagic shock[J]. Mil Med, 2010, 175(3): 166-172.

[5]Zager R A, Johnson A C, Becker K. Renal cortical pyruvate depletion during AKI [J]. J Am Soc Nephrol, 2014, 25(5): 998-1012.

[6]Mallet R T, Sun J, Knott E M,etal. Metabolic cardio protection by pyruvate: recent progress[J]. Exp Biol Med (Mayweed), 2005, 23(7): 435-443.

[7]車晉偉,胡森, 吳靜, 等. 燒傷休克犬腸粘膜血流量動(dòng)態(tài)監(jiān)測(cè)方法的研究[J]. 感染、炎癥、修復(fù), 2008, 9(1): 15-17.

[8]孫業(yè)祥，汪昌榮，陳俠英. 嚴(yán)重?zé)齻∪诵菘似谒釅A失衡類型及其機(jī)理的探討[J].中國(guó)燒傷創(chuàng)瘍雜志, 2003, 15 (4): 282-285.

[9]Cotton B A，Guy J S，Morris J A Jr,etal. The cellular，metabolic，and systemic consequences of aggressive fluid resuscitation strategies[J].Shock，2006，26(2)：115-121.

[10]Santry H P，Alam H B.Fluid resuscitation：past，present，and the future[J]. Shock，2010，33(3)：229-241.

[11]Su Fuhong, Wang Zhen, CaiYing,etal. Beneficial effects of ethyl pyruvate in septic shock from peritonitis[J]. Arch Surg, 2007, 142: 166-171.

[12]Schillinger W, Hunlich M, Sossalla S,etal. Intracoronary pyruvate in cardiogenic shock as an adjunctive therapy to catecholamines and intra-aortic balloon pump shows beneficial effects on hemodynamics [J]. Clin Res Cardiol, 2011,100(5):433-438.

[13]Ojha S, Goyal S, Kumari S,etal. Pyruvate attenuates cardiac dysfunction and oxidative stress in isoproterenol-induced cardiotoxicity[J]. Exp Toxicol Pathol, 2012, 64(4): 393-399.

[14]Olivencia-Yurvati A H, Blair J L, Baig M,etal. Pyruvate-enhanced cardio protection during surgery with cardiopulmonary bypass [J]. Cardiothoracic Vasc Anesth, 2003,17(6): 715-720.

[15]Yi J S, Kim T Y, Kim D K,etal. Systemic pyruvate administration markedly reduces infarcts and motor deficits in rat models of transient and permanent focal cerebral ischemia[J]. Neurobiol Dis, 2007, 26(1): 94-104.

[16]Capacchione J, Fontana J L, West S,etal. Pyruvate improves cerebral metabolism during hemorrhagic shock[J]. Am J Physiol, 2001, 281: H854-H864.

[17]Mongan P D, Capacchione J, West S,etal. Pyruvate improves redox status and decreases indicators of hepatic apoptosis during hemorrhagic shock in swine[J]. Am J Physiol, 2002, 283: H1634-H1644.

[18]Ochiai K, Zhang J, Gong G,etal. Effects of augmented delivery of pyruvate on my ocardial high-energy phosphate metabolism at high work state[J]. Am J Physiol Heart Circ Physiol, 2004, 286 (10) : 2237.

[19]Cai B L, Deitch E A, Grande D,etal. Anti-inflammatory resuscitation improves survival in hemorrhage with trauma[J]. J Trauma, 2009, 66(6): 1632-1640.

[20]Gou D M, Tan H J, Cai H J,etal. Pyruvate effects on red blood cells during in vitro cardiopulmonary bypass with dogs’ blood [J]. Artif Organs, 2012, 36(11) : 988-991.

[21]Sharma A B, Knott E M, Jian B,etal. Pyruvate improves cardiac electromechanical and metabolic recovery from cardiopulmonary arrest and resuscitation [J]. Resuscitation, 2005, 66: 71-81.

[22]Hu S, Bai X D, Liu X Q,etal. Pyruvate Ringer’s solution corrects lactic acidosis and prolongs survival during hemorrhagic shock in rats[J]. J Emerg Med, 2013, 45(6): 885-893.

(2015-03-25收稿2015-08-10修回)

(責(zé)任編輯武建虎)

Effects of sodium pyruvate Ringer’s solution on the lactic acidosis and plasma volume during intravenous resuscitation in dogs with 50%TBSA degree Ⅲ full thickness burn injury

GAO Mingjuan1, LI Juan1, WANG Xiaona1, HU Sen2, SHENG Zhiyong2, ZHANG Huiping2, and BAI Xiaodong1.

1.Burns and Plastic Surgery Department，The General Hospital of Chinese People’s Armed Police Forces, Beijing 100039, China；2. Key Research Laboratory of Tissue Repair and Regeneration of PLA, and Beijing Key Research Laboratory of Skin Injury and Repair Regeneration, First Hospital Affiliated to the Chinese PLA General Hospital, Beijing 100048, China

ObjectiveTo study the effects of sodium pyruvate Ringer’s solution on lactic acidosis and plasma volume during intravenous resuscitation in dogs with 50% TBSA degree Ⅲ full thickness burn injury. MethodsBeagle dogs with intubation of the carotid artery and jugular vein for 24 h were subjected to a 50% TBSA degree Ⅲ burns, and were divided into three groups: burn injury without fluid resuscitation (NR,n=8), burn injury with fluid Lac-Ringer (VL,n=10), and with fluid Pry-Ringer (VP，n=10). The two intravenous fluid resuscitation began at 30 minutes after burn with volume and rate consistent with the Parkland Formula. The arterial and venous blood were sampled at different time points after injury，and then mean arterial pressure, circulating plasma volume, artery blood gas analysis and lactic acid were measured at conscious state. ResultsTwo hours after burn, the mean arterial pressures in NR，VL and VP groups were(45.3±7.8)mmHg，(91.3±10.2)mmHg and(98.7±9.5)mmHg, respectively, which were significantly reduced(allP<0.05)compared with those before injury(41.7±6.0) mmHg，(142.3±6.1) mmHg and (142.8±5.5)mmHg，the change in plasma volume，pH value，PaO2had the same trend as the mean arterial pressure, blood lactate level significantly reduced(P<0.05). All measurements in NR group kept worsening, and all died within 24 h after burn; while those of two intravenous resuscitation groups improved gradually，VP group was significantly superior to VL group at 6 hour after rususcitation(allP<0.05). ConclusionsThe Pyr-Ringer may be superior to the standard Lac-Ringer in the improvement of lactic acidosis and plasma volume during intravenous resuscitation in dogs with 50%TBSA full thickness burn injury.

burns; shock; intravenous solution; pyruvate; plasma volume; lactic acidosis

軍隊(duì)十一五科研專項(xiàng)課題(06Z055)；發(fā)改委衛(wèi)星示范項(xiàng)目(2014號(hào))

高明娟，碩士，醫(yī)師。

1.100039北京，武警總醫(yī)院燒傷整形科；2.100048北京，解放軍總醫(yī)院第一附屬醫(yī)院燒傷研究所休克與多器官障礙實(shí)驗(yàn)室

白曉東，E-mail: baixiaotmu@126.com

R644