急性高容量血液稀释在老年患者肝肿瘤切除术前的应用效果分析
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摘要
目的分析老年肝肿瘤切除术患者术前应用羟乙基淀粉130/0.4电解质注射液、羟乙基淀粉130/0.4氯化钠注射液及乳酸林格液行急性高容量血液稀释(acute hypervolemic hemodilution,AHH)的效果。方法选取2017年7月至2018年1月西安交通大学第一附属医院接诊的拟行肝肿瘤切除术的老年患者72例为研究对象,按照随机数表法将其分为A组(25例)、B组(25例)与C组(22例)。术前30分钟三组患者分别应用羟乙基淀粉130/0.4电解质注射液、羟乙基淀粉130/0.4氯化钠注射液及乳酸林格液行AHH。术中监测患者心率、平均动脉压(mean arterial pressure,MAP)、中心静脉压(central venous pressure,CVP),于AHH前(T0)、AHH结束即刻(T1)、AHH后30分钟(T2)采血样监测血浆凝血酶原时间(prothrombin time,PT)、活化部分凝血活酶时间(activated partial thromboplastin time,APTT)、血栓弹力图(thromboela-stogram,TEG)参数及全血激活凝血时间(activated clotting time,ACT);于AHH前及术后检测K~+、Na~+、Mg~(2+)和Cl~-水平。结果 AHH后,与T0时比较,T1、T2时三组患者MAP均显著升高(P_均<0.05),但组间比较显示,三组MAP无显著性差异(P>0.05)。与T0时比较,T1、T2时三组患者CVP均显著升高(P_均<0.05);T2时,B组和C组CVP均显著高于同期A组(P_均<0.05);三组患者APTT、PT较T0时均显著延长(P_均<0.05);B组与C组APTT、PT均显著长于同期A组(P_均<0.05);与T0比较,B组与C组ACT、反应时间(R值)及凝固时间(K值)均明显延长(P_均<0.05),凝固角和最大血块强度(maximal amplitude,MA)均显著降低(P_均<0.05);组间比较,B组与C组ACT、R值及K值均显著高于同期A组(P_均<0.05),而MA均显著低于A组(P_均<0.05);B组与C组K~+、Cl~-水平较T0时显著升高,且均显著高于同期A组(P_均<0.05);B组与C组Na~+、Mg~(2+)水平较T0时显著降低(P_均<0.05),且均显著低于同期A组(P_均<0.05)。结论肝肿瘤切除术前对老年患者实施AHH是可行的,其安全性较高。羟乙基淀粉130/0.4电解质注射液在急性扩容后维持机体血流动力稳定、凝血功能及电解质平衡方面的效果要优于羟乙基淀粉130/0.4氯化钠注射液和乳酸林格液,具有更高的临床应用价值。
Objective To analyze the effects of acute hypervolemic hemodilution(AHH)on elderly patients before liver tumor resection.Method 72 cases of elderly patients scheduled for liver tumor resection in the First Affiliated Hospital of Xi'an Jiaotong University from July 2017 to January 2018 were selected as research subjects,and they were divided into group A (25 cases),group B (25 cases)and group C(22 cases)according to the random number table method.30 minutes before operation,patients of the three groups accepted AHH treatment by Hydroxyethyl starch 130/0.4 and electrolyte injection,Hydroxyethyl starch 130/0.4 and sodium chloride and Lactate Ringer's solution,respectively.Heart rate,mean arterial pressure(MAP)and central venous pressure(CVP)were monitored during the operation.Blood samples were collected before AHH(T0),immediately after AHH(T1)and 30 minutes after AHH(T3),including prothrombin time(PT),activated partial thromboplastin time(APTT),thromboela-stogram(TEG)and activated clotting time(ACT).Serum K~+,Na~+,Mg~(2+) and Cl~- levels were measured before AHH treatment and immediately after the operation.Result After AHH,compared with T0,MAP of the three groups was significantly increased at T1 and T2(P_(all)<0.05),while no significant difference was found among the three groups(P>0.05).Compared with T0,CVP of the three groups was markedly increased at T1 and T2(P_(all)<0.05).CVP of group B and group C was markedly higher than that of group A at T2(P_(all)<0.05).Compared with those at T0,APTT and PT of the three groups were significantly prolonged(P_(all)<0.05).APTT and PT of group B and group C were significantly longer than those of group A(P_(all)<0.05).Compared with T0,ACT,R and K value were significantly prolonged(P_(all)<0.05),while Angle and maximal amplitude(MA)were distinctly decreased in group B and group C(P_(all)<0.05).Inter-group comparison showed that ACT,R and K value were markedly higher(P_(all)<0.05),while MA was significantly lower in group B and group C(P<0.05).Compared with T0,K~+ and Cl~- were significantly increased in group B and group C(P<0.05),and they were significantly higher than those in group A at the same period(P_(all)<0.05).Na~+ and Mg~(2+) were distinctly decreased in group B and group C(P_(all)<0.05),and they were much lower than those in group A(P_(all)<0.05).Conclusion Preoperative AHH could be feasible in liver tumor resection for elderly patients and this treatment is entirely safe.The effects of Hydroxyethyl starch 130/0.4 and electrolyte injection on maintaining the stability of haemodynamics,coagulation function and electrolyte balance after acute expansion of blood volume are markedly better than Hydroxyethyl starch 130/0.4 and sodium chloride or Lactate Ringer's solution,indicating a higher clinical value.
Objective To analyze the effects of acute hypervolemic hemodilution(AHH)on elderly patients before liver tumor resection.Method 72 cases of elderly patients scheduled for liver tumor resection in the First Affiliated Hospital of Xi'an Jiaotong University from July 2017 to January 2018 were selected as research subjects,and they were divided into group A (25 cases),group B (25 cases)and group C(22 cases)according to the random number table method.30 minutes before operation,patients of the three groups accepted AHH treatment by Hydroxyethyl starch 130/0.4 and electrolyte injection,Hydroxyethyl starch 130/0.4 and sodium chloride and Lactate Ringer's solution,respectively.Heart rate,mean arterial pressure(MAP)and central venous pressure(CVP)were monitored during the operation.Blood samples were collected before AHH(T0),immediately after AHH(T1)and 30 minutes after AHH(T3),including prothrombin time(PT),activated partial thromboplastin time(APTT),thromboela-stogram(TEG)and activated clotting time(ACT).Serum K~+,Na~+,Mg~(2+) and Cl~- levels were measured before AHH treatment and immediately after the operation.Result After AHH,compared with T0,MAP of the three groups was significantly increased at T1 and T2(P_(all)<0.05),while no significant difference was found among the three groups(P>0.05).Compared with T0,CVP of the three groups was markedly increased at T1 and T2(P_(all)<0.05).CVP of group B and group C was markedly higher than that of group A at T2(P_(all)<0.05).Compared with those at T0,APTT and PT of the three groups were significantly prolonged(P_(all)<0.05).APTT and PT of group B and group C were significantly longer than those of group A(P_(all)<0.05).Compared with T0,ACT,R and K value were significantly prolonged(P_(all)<0.05),while Angle and maximal amplitude(MA)were distinctly decreased in group B and group C(P_(all)<0.05).Inter-group comparison showed that ACT,R and K value were markedly higher(P_(all)<0.05),while MA was significantly lower in group B and group C(P<0.05).Compared with T0,K~+ and Cl~- were significantly increased in group B and group C(P<0.05),and they were significantly higher than those in group A at the same period(P_(all)<0.05).Na~+ and Mg~(2+) were distinctly decreased in group B and group C(P_(all)<0.05),and they were much lower than those in group A(P_(all)<0.05).Conclusion Preoperative AHH could be feasible in liver tumor resection for elderly patients and this treatment is entirely safe.The effects of Hydroxyethyl starch 130/0.4 and electrolyte injection on maintaining the stability of haemodynamics,coagulation function and electrolyte balance after acute expansion of blood volume are markedly better than Hydroxyethyl starch 130/0.4 and sodium chloride or Lactate Ringer's solution,indicating a higher clinical value.
引文
[1]沈锋,吴孟超.提高肝癌外科疗效的近期研究[J].中国医学前沿杂志(电子版),2014,6(5):4-8.
[2]陈坚勇,李桂明,唐泽华.2008~2012年围麻醉期手术患者成分输血回顾性分析[J].中国输血杂志,2013,26(5):469-470.
[3]Timler D,Klepaczka J,Kasielska-Trojan A,et al.Analysis of complications after blood components'transfusions[J].Pol Przegl Chir,2015,87(4):166-173.
[4]Osterman JL,Arora S.Blood product transfusions and reactions[J].Emerg Med Clin North Am,2014,32(3):727-738.
[5]Wang P,Yan CY,Cai XJ.Acute hypervolemic hemodilution effect on oxygen metabolism and blood pharmacokinetics in patients undergoing acute laparotomy during induction of general anesthesia[J].Hepatogastroenterology,2014,61(136):2196-2199.
[6]史立凯,董海龙,赵蕊妮,等.高血容量血液稀释对老年患者围术期血流动力学的影响[J].心脏杂志,2014(4):472-476.
[7]郑少华,周晓云,姜伟,等.HES130/0.4电解质注射液与HES130/0.4氯化钠注射液急性高容量血液稀释用于患者血液保护效果的比较[J].中华麻醉学杂志,2016,36(7):835-838.
[8]赵玉彪,崔殿超,齐国宁,等.控制性降压联合急性高容量血液稀释在脊柱手术中的应用[J].中国医刊,2013,48(8):71-72.
[9]许幸,吴新民,薛张纲,等.全麻非心脏手术患者羟乙基淀粉130/0.4电解质注射液与羟乙基淀粉130/0.4氯化钠溶液容量治疗效果的比较:多中心、前瞻、随机、双盲、对照研究[J].中华麻醉学杂志,2011,31(10):1165-1169.
[10]Casutt M,Kristoffy A,Schuepfer G,et al.Effects on coagulation of balanced(130/0.42)and non-balanced(130/0.4)hydroxyethyl starch or gelatin compared with balanced Ringer's solution:an in vitro study using two different viscoelastic coagulation tests ROTEMTM and SONOCLOTTM[J].Br JAnaesth,2010,105(3):273-281.
[11]Schaden E,Wetzel L,Kozek-Langenecker S,et al.Effect of the carrier solution for hydroxyethyl starch on platelet aggregation and clot formation[J].Br J Anaesth,2012,109(4):572-577.
[12]庄伟强,张小霓,林财珠.急性高容量血液稀释对血液保护作用的研究进展[J].医学综述,2011,17(21):3311-3314.
[13]Hung MH,Zou C,Lin FS,et al.New 6%hydroxyethyl starch130/0.4 does not increase blood loss during major abdominal surgery-a randomized,controlled trial[J].J Formos Med Assoc,2014,113(7):429-435.
[14]Martin G,Bennett-Guerrero E,Wakeling H,et al.A prosp ective,randomized comparison of thromboelastographic coagul ation profile in patients receiving lactated Ringer's solution,6%hetastarch in a balanced-saline vehicle,or 6%hetas tarch in saline during major surgery[J].J Cardiothorac Vasc Anesth,2002,16(4):441-446.
[15]Boldt J,Wolf M,Mengistu A.A new plasma-adapted hydroxyethylstarch preparation:in vitro coagulation studies using thrombelastography and whole blood aggregometry[J].Anesth Analg,2007,104(2):425-430.
[16]Kreimeier U,Messmer K.Perioperative hemodilution[J].Transfus Apheresis Sci,2002,27(1):59-72.
[17]王天龙.羟乙基淀粉电解质注射液的研究进展[J].中华麻醉学杂志,2013,33(12):1417-1422.
[18]Teloh JK,Ferenz KB,Petrat F,et a1.Acid-base and electrolyte status during normovolemic hemodilution with succinylated gelatin or HES-containing volume replacement solutions in rats[J].PLoS One,2013,8(9):e72848.
[19]Ishihara H.Kidney function after the intraoperative use of6%tetrastarches(HES 130/0.4 and 0.42)[J].J Anesth,2014,28(2):249-256.
[2]陈坚勇,李桂明,唐泽华.2008~2012年围麻醉期手术患者成分输血回顾性分析[J].中国输血杂志,2013,26(5):469-470.
[3]Timler D,Klepaczka J,Kasielska-Trojan A,et al.Analysis of complications after blood components'transfusions[J].Pol Przegl Chir,2015,87(4):166-173.
[4]Osterman JL,Arora S.Blood product transfusions and reactions[J].Emerg Med Clin North Am,2014,32(3):727-738.
[5]Wang P,Yan CY,Cai XJ.Acute hypervolemic hemodilution effect on oxygen metabolism and blood pharmacokinetics in patients undergoing acute laparotomy during induction of general anesthesia[J].Hepatogastroenterology,2014,61(136):2196-2199.
[6]史立凯,董海龙,赵蕊妮,等.高血容量血液稀释对老年患者围术期血流动力学的影响[J].心脏杂志,2014(4):472-476.
[7]郑少华,周晓云,姜伟,等.HES130/0.4电解质注射液与HES130/0.4氯化钠注射液急性高容量血液稀释用于患者血液保护效果的比较[J].中华麻醉学杂志,2016,36(7):835-838.
[8]赵玉彪,崔殿超,齐国宁,等.控制性降压联合急性高容量血液稀释在脊柱手术中的应用[J].中国医刊,2013,48(8):71-72.
[9]许幸,吴新民,薛张纲,等.全麻非心脏手术患者羟乙基淀粉130/0.4电解质注射液与羟乙基淀粉130/0.4氯化钠溶液容量治疗效果的比较:多中心、前瞻、随机、双盲、对照研究[J].中华麻醉学杂志,2011,31(10):1165-1169.
[10]Casutt M,Kristoffy A,Schuepfer G,et al.Effects on coagulation of balanced(130/0.42)and non-balanced(130/0.4)hydroxyethyl starch or gelatin compared with balanced Ringer's solution:an in vitro study using two different viscoelastic coagulation tests ROTEMTM and SONOCLOTTM[J].Br JAnaesth,2010,105(3):273-281.
[11]Schaden E,Wetzel L,Kozek-Langenecker S,et al.Effect of the carrier solution for hydroxyethyl starch on platelet aggregation and clot formation[J].Br J Anaesth,2012,109(4):572-577.
[12]庄伟强,张小霓,林财珠.急性高容量血液稀释对血液保护作用的研究进展[J].医学综述,2011,17(21):3311-3314.
[13]Hung MH,Zou C,Lin FS,et al.New 6%hydroxyethyl starch130/0.4 does not increase blood loss during major abdominal surgery-a randomized,controlled trial[J].J Formos Med Assoc,2014,113(7):429-435.
[14]Martin G,Bennett-Guerrero E,Wakeling H,et al.A prosp ective,randomized comparison of thromboelastographic coagul ation profile in patients receiving lactated Ringer's solution,6%hetastarch in a balanced-saline vehicle,or 6%hetas tarch in saline during major surgery[J].J Cardiothorac Vasc Anesth,2002,16(4):441-446.
[15]Boldt J,Wolf M,Mengistu A.A new plasma-adapted hydroxyethylstarch preparation:in vitro coagulation studies using thrombelastography and whole blood aggregometry[J].Anesth Analg,2007,104(2):425-430.
[16]Kreimeier U,Messmer K.Perioperative hemodilution[J].Transfus Apheresis Sci,2002,27(1):59-72.
[17]王天龙.羟乙基淀粉电解质注射液的研究进展[J].中华麻醉学杂志,2013,33(12):1417-1422.
[18]Teloh JK,Ferenz KB,Petrat F,et a1.Acid-base and electrolyte status during normovolemic hemodilution with succinylated gelatin or HES-containing volume replacement solutions in rats[J].PLoS One,2013,8(9):e72848.
[19]Ishihara H.Kidney function after the intraoperative use of6%tetrastarches(HES 130/0.4 and 0.42)[J].J Anesth,2014,28(2):249-256.