【作者】 杨光；

【导师】 高金贵；

【作者基本信息】 河北医科大学 ， 麻醉学（专业学位）， 2015， 硕士

【摘要】 急性高容量血液稀释(AHH)是当前血液保护的主要方法之一,目的是减少出血和输血,既可节约用血,又可减少异体输血所引起的各种不良反应和并发症,进而达到血液保护的措施,因此临床应用日渐广泛。但因对其实施方法、机体对其耐受程度等问题观点各有不同,研究结果并不一致。AHH的安全性及有效性尚需进一步探讨,以全面合理地评估和使用这种血液保护方法。目的:比较不同液体用于急性高容量血液稀释对脑膜瘤切除术病人凝血功能的影响。方法:选择30例ASAⅠ或Ⅱ的择期行脑膜瘤切除术的病人随机分成三组,乳酸钠林格注射液(R组,n=10)、6%羟乙基淀粉130/0.4氯化钠注射液组(H组),(H组,n=10)、4%琥珀酰明胶注射液组(G组)(G组,n=10)入室后开放外周静脉通路,输注乳酸钠林格注射液组6~8ml·kg-1·h-1。1%利多卡因局麻下行桡动脉穿刺置管术,监测有创动脉压。全麻诱导均静脉注射阿托品0.5mg,咪达唑仑0.1mg·kg-1,舒芬太尼0.5μg·kg-1,丙泊酚2mg·kg-1,顺阿曲库铵0.15mg·kg-1。麻醉维持静脉注射瑞芬太尼注射液0.1~0.3μg·kg-1·min-1,丙泊酚4~6mg·kg-1·h-1,间断追加顺阿曲库铵0.05mg·kg-1维持肌松。气管插管机械通气后行右颈内静脉穿刺置管术,补液并监测CVP。分别输入乳酸钠林格注射液、6%羟乙基淀粉130/0.4氯化钠注射液或4%琥珀酰明胶注射液,20 ml/kg,(25±5)min内输完,术中当HGB<80g/L,HCT<25%时输入悬浮红细胞,以维持HCT>25%。分别在AHH前(T0),AHH后即刻(T1),AHH后30min(T2)采静脉血测快速血栓弹力图各参数[反应时间(TEG-ACT,R)、血凝块形成时间(K)、Angel角、最大振辐(MA)]、血常规(PLT、HCT)、CCT(PT、APTT),连续监测并记录HR、MAP、CVP、Sp O2、Pet CO2。所有数据采用IBM SPSS Statistics 21统计学软件进行分析,计量资料以均数±标准差(x±s)表示,组间比较采用单因素方差分析,组内比较采用重复测量设计的方差分析,计数资料比较采用卡方检验。P<0.05为差异有统计学意义。结果:1一般情况:三组病人的年龄、性别比、体重和扩容时间扩容量差异无统计学意义(P>0.05),(Table 1)。2在AHH前HR、MAP、CVP、PLT组间差异无统计学意义(P>0.05),AHH后,各组HR差异无统计学意义(P>0.05),MAP均升高且H组与G组组内较AHH前差异有统计学意义(P<0.01),各组Pet CO2、ECG在AHH前后未见异常变化。CVP组内比较T1,T2与T0比较明显升高(P<0.05或P<0.01),组间比较H组、G组与R组比较差异均有统计学意义(P<0.01)。扩容率H组、G组明显高于R组(P<0.01)。PLT组内比较T1,T2与T0比较明显减少(P<0.05或P<0.01),AHH后组间比较H组、G组与R组比较差异均有统计学意义(P<0.01),(Table2)。3 APTT、PT:三组病人在AHH前组间差异无统计学意义(P>0.05)。组内比较H组与G组的T1 T2与T0比较时间明显延长(P<0.05或P<0.01)AHH后组间比较H组、G组与R组比较差异均有统计学意义(P<0.05或P<0.01),(Table 3)。4 r-TEG各参数比较:各参数三组病人在AHH前组间差异无统计学意义(P>0.05)。TEG-ACT组内比较H组与G组的T1,T2与T0比较时间明显延长(P<0.01),AHH后组间比较H组、G组与R组比较差异均有统计学意义(P<0.05或P<0.01)。R值组内比较各组T1,T2与T0比较差异无统计学意义(P>0.05),AHH后组间比较R值H组、G组与R组比较差异均有统计学意义(P<0.05或P<0.01)。K值与Angle角组间比较差异无统计学意义(P>0.05),组内比较H组的T1,T2与T0比较差异有统计学意义(P<0.05)。MA值组内比较H组、G组的T1,T2与T0比较明显减小(P<0.05),组间比较H组、G组与R组比较差异均有统计学意义(P<0.05或P<0.01),(Table 4)。结论:1术前以20 ml/kg,(25±5)min输注速度和输注量行AHH对于脑膜瘤手术病人是安全可行的。2晶体液与胶体液用于脑膜瘤切除手术病人均可有效扩容,6%羟乙基淀粉130/0.4氯化钠注射液与4%琥珀酰明胶注射液扩容效果优于乳酸钠林格注射液,更适宜用于术前AHH。3与乳酸钠林格注射液相比,6%羟乙基淀粉130/0.4氯化钠注射液与4%琥珀酰明胶对凝血功能影响明显,但各参数均在安全范围内。4 r-TEG实时监测凝血的全过程,与CCT相比更为全面,迅速,适于围术期患者凝血功能的适时评估。更多还原

【Abstract】 Acute hypervolemic hemodilution(AHH) is an effective method of blood conservation, the purpose of which is to reduce bleeding and blood transfusion and avoid a variety of adverse reactions and complications caused by allogeneic blood transfusion. In order to achieve the purpose of blood conservation, the clinical applications become increasingly widespread. Because of different opinions upon the implementation methods, the degree of tolerance, we try to explore the safety, effectiveness and use of this kind of blood protection method comprehensively.Objective: To compare the influences of blood coagulation function upon different liquids for acute hypervolemic hemodilution in patients undergoing meningioma resection.Methods: Thirty ASAⅠorⅡadult patients, undergoing scheduled elective meningioma operation were randomly divided into 3 groups: Group R(AHH with lactate Ringer’s solution), Group H(AHH with 6%Hydroxyethyl Starch130/0.4), Group G(AHH with 4%Gelofusine), with 10 patients in each group. In all patients, lactate Ringer’s solution 6-8mlkg-1·h-1 was infused to compensate for preoperative fluid restriction after midnight. Left radialis artery was cannulated for intra-arterial Pressure monitoring before induction of anesthesia. All patients had same general anesthetic techiques. The patients were premedicated with intravenous injection of atropine 0.5mg. Anesthesia was induced with midazolam 0.1mg·kg-1, Sufentanil o.5μg·kg-1, propofol 2mg·kg-1 and cisatracurium 0.15mg·kg-1 and maintained with propofol 4-6mg·kg-1·h-1 and remifentanil 0.1-0.3μg·kg-1·min-1. Muscle relaxation was maintained with intermittent intravenous boluses of cisatracurium. The patients were mechanieally ventilated(VT=8-10ml·kg-1, RR=10-12bpm) after tracheal intubation and right internal jugular vein was cannulated for fluid resuscitation and CVP monitoring. AHH was Performed by infusing 20ml·kg-1 solution(Group R, AHHD with laetated Ringer’s solution; Group H, AHH with 6%Hydroxyethyl Starch130/0.4, Group G, AHH with 4%Gelofusine) within(25±5) min after induction of anesthesia. Intraoperative blood loss was replaced with equal volume of 6%Hydroxyethyl Starch130/0.4 or 4%Gelofusine. Blood transfusion was considered to maintain HCT>25% when HGB<80g·L-1 and HCT<25%. Venous blood samples were taken before AHH(T0), at the end of AHH(T1), 30 minute after AHH(T2) for determining the following data: Blood routine examination(including HCT, PLT), CCT(including PT, APTT), parameters of rapid thrombelastography(TEG-ACT, R, K, Angle, MA). HR, MAP, CVP, Sp O2, Pet CO2 were monitored continually during the whole operation. Measurement data was expressed as mean ± standard deviation( x ±s). Statistical package(IBM SPSS Statistics 21) was used for processing all the data. Groups were compared using univariate analysis of variance, Within group was compared using analysis of variance for repeated measurements. Count data using chi square comparing test. P<0.05 was considered that the difference has statistical significance.Results: 1 General data: The there groups were comparable with respect to age, sex ratio, body weight, blood volume expansion time and blood volume expansion(P>0.05)(Table 1). 2 There were no statistically significant differences among groups on MAP, CVP, PLT before AHH(P>0.05). After AHH, HR had no significant difference in all three groups(P>0.05). Within three groups, MAP increased significantly after AHH compared with baseline value before AHH in group H and G(P<0.01). ECG and Pet CO2 had no abnormal changes in the whole AHH. Within three groups, the CVP increased significantly at T1, T2 compared with T0(P<0.05 or P<0.01). Compare between groups: There were statistically significant differences between group H, G and group R on CVP after AHH(P<0.01). Group H and group G were significantly higher than that in group R on blood volume expansion rate(P<0.01). Changes on PLT: Within three groups, the PLT decreased significantly at T1, T2 compared with T0(P<0.05 or P<0.01). Compare between groups: There were statistically significant differences between group H, G and group R after AHH(P<0.01)(Table 2). 3 Changes on APTT, PT: There were no statistically significant differences among three groups before AHH(P>0.05). Within three groups, the time prolonged significantly at T1, T2 compared with T0 in group H and group G(P<0.05 or P<0.01). Compare between groups: There were statistically significant differences between group H, G and group R after AHH(P<0.05 or P<0.01)(Table 3). 4 Change on r-TEG parameters: All the parameters among three groups had no significant differences before AHH. TEG-ACT: Within three groups, the TEG-ACT prolonged significantly at T1, T2 compared with T0 in group H and group G(P<0.01). Compare between groups: There were statistically significant differences between group H, G and group R after AHH(P<0.05 or P<0.01). R-time: The R-time had no statistically significant differences within three groups(P>0.05). Compare between groups: There were statistically significant differences between group H, G and group R after AHH(P<0.05 or P<0.01). K-time and Angle: There were no statistically significant differences among groups on K-time and Angle(P>0.05). Within three groups, K-time and Angle had statistically significantly at T1, T2 compared with T0 in group H(P<0.05). MA: Within three groups, the MA decreased significantly at T1, T2 compared with T0 in group H and group G(P<0.05). Compare between groups: There were statistically significant differences between group H, G and group R after AHH(P<0.05 or P<0.01)(Table 4).Conclusions: 1 AHH was Performed by infusing 20ml·kg-1 solution within(25±5) min, which is feasible and safe for patients undergoing meningioma. 2 Crystalloid and colloid solution can effectively expand the blood volume for meningioma resection patients. Compared with lactated Ringer’s solution on the effect of expanding the blood volume, 6%Hydroxyethyl starch 130/0.4 or 4%Gelofusine is a better choice,which is also suitable for preoperative AHH.3 Compared with lactated Ringer’s solution, 6%Hydroxyethyl Starch 130/0.4 and 4%Gelofusine have significant influence on blood coagulation, however, all parameters were within the safe levels. 4 r-TEG is more comprehensive than CCT for the whole process of coagulation, and then the time of results is shorter than CCT. r-TEG can be used for rapid clinical evaluation.更多还原