心脏手术患者肝素-鱼精蛋白抗凝方案优化的临床研究
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摘要
目的比较肝素-鱼精蛋白双滴定法与传统法对体外循环(CPB)心脏直视手术患者术后出血的影响。方法选择全身麻醉体外循环患者90例,随机分为三组。传统法组(A组,n=30),给予患者375 U/kg肝素,鱼精蛋白拮抗量为初始肝素剂量与鱼精蛋白125 U:1.2 mg;肝素滴定法组(B组,n=30),根据肝素滴定法结果给予肝素;肝素-鱼精蛋白双滴定法组(C组,n=30),肝素滴定法结合鱼精蛋白滴定法。记录患者一般资料,比较三组患者术中和术后输血量,术后24 h胸腔引流量,以及手术相关并发症等指标。结果 B组与C组肝素用量小于A组(P<0.05)。C组鱼精蛋白用量小于A组与B组(P<0.05)。术后24 h胸腔引流量A组大于B组与C组(P<0.05)。结论目前临床使用的传统法与肝素-鱼精蛋白双滴定法相比,滴定法个体化给予肝素、鱼精蛋白能减少CPB后患者出血量。
Objective To compare the effect of heparin protamine double titration with traditional meth-ods on postoperative bleeding in patients underwent cardiopulmonary bypass(CPB). Methods Ninety adultpatients scheduled to elective CPB by open heart surgery were randomly divided into three groups. In the Conven-tional Group(group A,n = 30),375 U/kg heparin was administered. The amount of protamine was in proportionto 125 U∶1.2 mg base on the initial heparin dose. In the Heparin Titration Group(group B,n = 30),heparin wasgiven according to the effect of heparin titration. In the Heparin and Protamine Double Titration Group(group C,n = 30),heparin titration combined with protamine titration were administered. The general data of the patientswere recorded. The blood transfusion volume during and after operation,volume of thoracic drainage within24 hours after operation,operative complications were compared among the 3 groups. Results Group B andgroup C heparin dosage were less than the group A(P < 0.05). The protamine dosage in group C was less than thatin group A and group B(P < 0.05). The thoracic drainage volume within 24 hours after operation was higher inthe group A than group B and group C(P < 0.05). Conclusion Compared the traditional anticoagulation withheparin and protamine double titration,the latter individualized anticoagulation can reduce the amount of bleedingafter CPB.
Objective To compare the effect of heparin protamine double titration with traditional meth-ods on postoperative bleeding in patients underwent cardiopulmonary bypass(CPB). Methods Ninety adultpatients scheduled to elective CPB by open heart surgery were randomly divided into three groups. In the Conven-tional Group(group A,n = 30),375 U/kg heparin was administered. The amount of protamine was in proportionto 125 U∶1.2 mg base on the initial heparin dose. In the Heparin Titration Group(group B,n = 30),heparin wasgiven according to the effect of heparin titration. In the Heparin and Protamine Double Titration Group(group C,n = 30),heparin titration combined with protamine titration were administered. The general data of the patientswere recorded. The blood transfusion volume during and after operation,volume of thoracic drainage within24 hours after operation,operative complications were compared among the 3 groups. Results Group B andgroup C heparin dosage were less than the group A(P < 0.05). The protamine dosage in group C was less than thatin group A and group B(P < 0.05). The thoracic drainage volume within 24 hours after operation was higher inthe group A than group B and group C(P < 0.05). Conclusion Compared the traditional anticoagulation withheparin and protamine double titration,the latter individualized anticoagulation can reduce the amount of bleedingafter CPB.
引文
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[7]BAMBRAH R K,PHAM D C,ZAIDEN R,et al.Heparin-induced thrombocytopenia[J].Clin Adv Hematol Oncol,2011,9(8):594-599.
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[9]ORLIKOWSKI C E,ROCKE D A,MURRAY W B,et al.Thrombelastography changes in pre-eclampsia and eclampsia[J].Br J Anaesth,1996,77(2):157-161.
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[12]王正坤,刘涌,叶玉萍.地氟醚和七氟醚在子宫外产时手术麻醉中应用价值比较[J].现代医院,2017,17(2):277-279.
[13]KOSTER A,BORGERMANN J,GUMMERT J,et al.Prot-amine overdose and its impact on coagulation,bleeding,andtransfusions after cardiopulmonary bypass:results of a random-ized double-blind controlled pilot study[J].Clin Appl ThrombHemost,2014,20(3):290-295.
[14]李怀友,唐从耀,黄小甜.血浆D-二聚体及C反应蛋白在急诊创伤性休克患者预后评估中的价值[J].现代医院,2016,16(11):1617-1618.
[15]方强,石应康,王兰兰,等.低剂量鱼精蛋白拮抗肝素围体外循环期血浆肝素浓度变化与凝血功能损害[J].实用医学杂志,2005,21(2):133-135.
[16]RUNGE M,MOLLER C H,STEINBRUCHEL D A.Increasedaccuracy in heparin and protamine administration decreasesbleeding:a pilot study[J].J Extra Corpor Technol,2009,41(1):10-14.
[2]DESPOTIS G J,SKUBAS N J,GOODNOUGH L T.Optimalmanagement of bleeding and transfusion in patients undergoingcardiac surgery[J].Semin Thorac Cardiovasc Surg,1999,11(2):84-104.
[3]KNAPIK P,CIESLA D,PRZYBYLSKI R.The influence ofheparin resistance on postoperative complications in patients un-dergoing coronary surgery[J].Med Sci Monit,2012,18(2):CR105-111.
[4]SHIBASAKI M,NAKAJIMA Y,KOJIMA A.How much dos-age of heparin do you administer?The relationship betweenheparin dosage and activated coagulation time(ACT)value dur-ing cardiovascular surgery:a multi center investigations[J].Masui,2010,59(4):535-539.
[5]BULL B S,HUSE W M,BRAUER F S.Heparin therapy duringextracorporeal circulation.II.The use of a dose-response curveto individualize heparin and protamine dosage[J].J ThoracCardiovasc Surg,1975,69(5):685-689.
[6]HANS G A,BESSER M W.The place of viscoelastic testing inclinical practice[J].Br J Haematol,2016,173(1):37-48.
[7]BAMBRAH R K,PHAM D C,ZAIDEN R,et al.Heparin-induced thrombocytopenia[J].Clin Adv Hematol Oncol,2011,9(8):594-599.
[8]IGNJATOVIC V,THAN J,SUMMERHAYES R,et al.Hemo-static response in paediatric patients undergoing cardiopulmo-nary bypass surgery[J].Pediatr Cardiol,2011,32(5):621-627.
[9]ORLIKOWSKI C E,ROCKE D A,MURRAY W B,et al.Thrombelastography changes in pre-eclampsia and eclampsia[J].Br J Anaesth,1996,77(2):157-161.
[10]JOHANSSON P I,STISSING T,BOCHSEN L,et al.Thrombe-lastography and tromboelastometry in assessing coagulopathy intrauma[J].Scand J Trauma Resusc Emerg Med,2009,17:45.
[11]DICKINSON K J,TROXLER M,HOMER-VANNIASINKAM S.The surgical application of point-of-care haemostasis and plate-let function testing[J].Br J Surg,2008,95(11):1317-1330.
[12]王正坤,刘涌,叶玉萍.地氟醚和七氟醚在子宫外产时手术麻醉中应用价值比较[J].现代医院,2017,17(2):277-279.
[13]KOSTER A,BORGERMANN J,GUMMERT J,et al.Prot-amine overdose and its impact on coagulation,bleeding,andtransfusions after cardiopulmonary bypass:results of a random-ized double-blind controlled pilot study[J].Clin Appl ThrombHemost,2014,20(3):290-295.
[14]李怀友,唐从耀,黄小甜.血浆D-二聚体及C反应蛋白在急诊创伤性休克患者预后评估中的价值[J].现代医院,2016,16(11):1617-1618.
[15]方强,石应康,王兰兰,等.低剂量鱼精蛋白拮抗肝素围体外循环期血浆肝素浓度变化与凝血功能损害[J].实用医学杂志,2005,21(2):133-135.
[16]RUNGE M,MOLLER C H,STEINBRUCHEL D A.Increasedaccuracy in heparin and protamine administration decreasesbleeding:a pilot study[J].J Extra Corpor Technol,2009,41(1):10-14.