Ahrns Karla S
University of Michigan Trauma Burn Center, 1500 East Medical Center Drive, Room UH1C340, Ann Arbor, MI 48109, USA.
Crit Care Nurs Clin North Am. 2004 Mar;16(1):75-98. doi: 10.1016/j.ccell.2003.09.007.
Bum shock is a complex process involving a series of intertwined physiologic responses to injury that require more rigorous intervention than simply a change in fluid tonicity, fluid composition, or fluid resuscitation volume. Controversy ensues over monitoring techniques and resuscitation goals, in part because the identification of true markers of perfusion is clouded by intradependence of endpoints on other metabolic processes. The persistence of cellular hypoperfusion in patients who have been deemed adequately resuscitated by global indices supports the growing realization that failure of conventional endpoint-monitoring strategies to detect compensated bum shock can lead to significant organ injury from SIRS or MODS. Current endpoints should be interpreted in the aggregate, because none have yet been demonstrated to reflect tissue perfusion status independently and accurately. Numerous technologically advanced endpoints to predict patient outcome, which may be useful in determining futility of treatment or end-of-life decisions, are now available. Still lack-ing, however, is a reliable tool proven to improve outcome that can guide bum shock resuscitation therapies successfully. Exciting new research in tissue oxygenation and perfusion has revealed that damaging mediator cascades and irreversible microvascular changes may preclude complete resolution of bum shock solely through restoration of oxygen delivery. Because bum patients now frequently survive the early resuscitation phase. the focus should be on controlling derangements in oxygen use and correcting occult hypoperfusion to reduce later adverse patient outcomes from SIRS, sepsis, and MODS. Bum-specific research on resuscitation endpoints and monitoring strategies lags behind research in other patient populations. Present standards and monitoring guidelines for bum shock resuscitation should be critically evaluated and based on true, scientifically validated data rather than on observational studies or personal beliefs. Thus the continuing challenge for clinicians and researchers:burn centers must collaborate to perform large, multi-center studies to evaluate critically and to prove resuscitation endpoints and therapies. Future technologies targeted at microcirculatory perfusion and cellular oxygenation offer an exciting promise for less invasive, easily accessible, more accurate endpoints and treatments for bum shock resuscitation.
烧伤休克是一个复杂的过程，涉及对损伤的一系列相互交织的生理反应，需要比单纯改变液体张力、液体成分或液体复苏量更严格的干预。关于监测技术和复苏目标存在争议，部分原因是灌注的真正标志物的识别因终点与其他代谢过程的相互依赖性而变得模糊。那些通过整体指标被认为已得到充分复苏的患者中，细胞灌注不足持续存在，这支持了一种越来越强烈的认识，即传统终点监测策略未能检测到代偿性烧伤休克会导致SIRS或MODS引起的严重器官损伤。目前的终点应综合解读，因为尚无任何一项终点被证明能独立且准确地反映组织灌注状态。现在有许多技术先进的终点可用于预测患者预后，这在确定治疗的无效性或临终决策时可能有用。然而，仍然缺乏一种经证实能改善预后的可靠工具来成功指导烧伤休克复苏治疗。组织氧合和灌注方面令人兴奋的新研究表明，损伤介质级联反应和不可逆的微血管变化可能使仅通过恢复氧输送来完全解决烧伤休克变得不可能。由于烧伤患者现在常常能度过早期复苏阶段，重点应放在控制氧利用紊乱和纠正隐匿性灌注不足上，以减少后期SIRS、脓毒症和MODS给患者带来的不良后果。烧伤特异性的复苏终点和监测策略研究落后于其他患者群体的研究。烧伤休克复苏的现行标准和监测指南应受到严格评估，并基于真实的、经过科学验证的数据，而非观察性研究或个人观点。因此，临床医生和研究人员面临持续的挑战：烧伤中心必须合作开展大型多中心研究，以严格评估并证明复苏终点和治疗方法。针对微循环灌注和细胞氧合的未来技术为烧伤休克复苏提供了令人兴奋的前景，有望实现侵入性更小、更易获取、更准确的终点和治疗方法。
