微通道经皮肾镜取石术中灌注液吸收对机体影响的研究
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摘要
【目的】探讨微通道经皮肾镜取石术(mPNL)中灌注液吸收对机体血流动力学、血生化和相关激素水平所产生的影响,进一步评价mPNL手术的安全性。
【方法】2007年1月至2008年2月对128例肾结石或嵌顿性输尿管上段结石的患者实施微通道经皮肾镜取石术。术中用生理盐水(NS)作为灌注液,灌注速度＜200ml·min~(-1)。灌注前、术中每30min及术毕记录心率(HR)、平均动脉压(MAP)和外周血氧饱和度(SpO_2);术前、术后监测血红蛋白(Hb)、红细胞压积(Hct)、血浆渗透压(POP)、血电解质(Na~+、K~+、Cl~-)、血肌酐(Cre)、血尿素氮(BUN)及肾素、血管紧张素Ⅱ和醛固酮等相关指标的水平。
【结果】128例手术全部获得成功。术中灌注时间为79.45±31.21min,灌注液用量为22.43±12.08L。所有患者均无液体吸收综合征及其它严重并发症发生,无输血。术中心率随着灌注时间延长而加快,各时间段之间的差异有显著性;术后的血浆渗透压、血清Cl~-、肾素和血肌酐较术前增高,其差异有显著性;而术后血红蛋白、红细胞压积、血清K~+、血尿素氮较术前降低,差异有显著性;平均动脉压、外周血氧饱和度、血清Na~+、醛固酮和血管紧张素Ⅱ手术前后的变化无差异性。
【结论】微通道经皮肾镜取石术中存在着一定的灌注液吸收。对于液体代偿功能正常的患者,一定量的液体吸收不会引起血流动力学、血生化及相关激素水平的严重的病理生理改变而导致液体吸收综合征的发生。但如果手术时间过长,术中手术通道丢失,肾盂、肾实质或输尿管穿孔则可能会由于大量的液体吸收而导致吸收综合征的发生。因此,微通道经皮肾镜取石术中对相关指标的监测,特别是对血流动力学指标的监测,对帮助早期发现和诊断液体吸收综合征具有重要的临床意义。
[Objective]To determine the effects of irrigation fluid's absorption on system hemodynamics,fluid-electrolyte and hormone during mini-percutaneous nephrolithotomy.
[Methods]In this study 128 patients with renal calculus or calculus of superior ureter from 2007/01 to 2008/02 were collected.They all underwent mini-percutaneous nephrolithotomy.0.9%NaCl was used as irrigant during operation.The speed of irrigation was less than 200ml·min~(-1).Heart rate(HR),mean arterial blood pressure (MAP)and pulse oxygen saturation(SpO_2)were recorded before and after irrigation and during irrigation every 30min.Hemoglobin(Hb),hematocrit(Hct),plasma osmotic pressure(POP),Na~+,K~+,Cl~-,serum creatinine(Cre),blood urea nitrogen (BUN),renin,angiotensinⅡand aldosterone were determined before and after operation.
[Results]All the operations were completed successfully.The mean irrigation time was 79.45±31.21min,and the mean irrigation fluid volume was 22.43±12.08L.No irrigation fluid absorption syndrome and other serious surgery-related complication occurred,did blood transfusion neigther.During irrigation HR speeded up accompanied with the irrigation time.HR was significantly different between every two stages.When compared with before operation,POP,Cl~-,renin and Cre were significantly increased after operation;Hb,Hct,K~+ and BUN were significantly decreased after operation;MAP,SpO_2,Na~+,aldosterone and angiotensinⅡdid not change significantly after operation.
[Conclusion]Irrigation fluid's absorption was observed during mini-percutaneous nephrolithotomy.No significant changes were found in hemodynamics, fluid-electrolyte balance and hormone for those patients with normal compensation of body fluid.But some complications might take place if extension of operation time, loss of tunnel,perforation of renal pelvis,renal parenchyma and ureter exist during mini-percutaneous nephrolithotomy.These complications might lead to irrigation fluid absorption syndrome.Therefore,the monitoring of hemodynamics, fluid-electrolyte balance and hormone,especially hemodynamics,was very important to discover irrigation fluid absorption syndrome in time.
【方法】2007年1月至2008年2月对128例肾结石或嵌顿性输尿管上段结石的患者实施微通道经皮肾镜取石术。术中用生理盐水(NS)作为灌注液,灌注速度＜200ml·min~(-1)。灌注前、术中每30min及术毕记录心率(HR)、平均动脉压(MAP)和外周血氧饱和度(SpO_2);术前、术后监测血红蛋白(Hb)、红细胞压积(Hct)、血浆渗透压(POP)、血电解质(Na~+、K~+、Cl~-)、血肌酐(Cre)、血尿素氮(BUN)及肾素、血管紧张素Ⅱ和醛固酮等相关指标的水平。
【结果】128例手术全部获得成功。术中灌注时间为79.45±31.21min,灌注液用量为22.43±12.08L。所有患者均无液体吸收综合征及其它严重并发症发生,无输血。术中心率随着灌注时间延长而加快,各时间段之间的差异有显著性;术后的血浆渗透压、血清Cl~-、肾素和血肌酐较术前增高,其差异有显著性;而术后血红蛋白、红细胞压积、血清K~+、血尿素氮较术前降低,差异有显著性;平均动脉压、外周血氧饱和度、血清Na~+、醛固酮和血管紧张素Ⅱ手术前后的变化无差异性。
【结论】微通道经皮肾镜取石术中存在着一定的灌注液吸收。对于液体代偿功能正常的患者,一定量的液体吸收不会引起血流动力学、血生化及相关激素水平的严重的病理生理改变而导致液体吸收综合征的发生。但如果手术时间过长,术中手术通道丢失,肾盂、肾实质或输尿管穿孔则可能会由于大量的液体吸收而导致吸收综合征的发生。因此,微通道经皮肾镜取石术中对相关指标的监测,特别是对血流动力学指标的监测,对帮助早期发现和诊断液体吸收综合征具有重要的临床意义。
[Objective]To determine the effects of irrigation fluid's absorption on system hemodynamics,fluid-electrolyte and hormone during mini-percutaneous nephrolithotomy.
[Methods]In this study 128 patients with renal calculus or calculus of superior ureter from 2007/01 to 2008/02 were collected.They all underwent mini-percutaneous nephrolithotomy.0.9%NaCl was used as irrigant during operation.The speed of irrigation was less than 200ml·min~(-1).Heart rate(HR),mean arterial blood pressure (MAP)and pulse oxygen saturation(SpO_2)were recorded before and after irrigation and during irrigation every 30min.Hemoglobin(Hb),hematocrit(Hct),plasma osmotic pressure(POP),Na~+,K~+,Cl~-,serum creatinine(Cre),blood urea nitrogen (BUN),renin,angiotensinⅡand aldosterone were determined before and after operation.
[Results]All the operations were completed successfully.The mean irrigation time was 79.45±31.21min,and the mean irrigation fluid volume was 22.43±12.08L.No irrigation fluid absorption syndrome and other serious surgery-related complication occurred,did blood transfusion neigther.During irrigation HR speeded up accompanied with the irrigation time.HR was significantly different between every two stages.When compared with before operation,POP,Cl~-,renin and Cre were significantly increased after operation;Hb,Hct,K~+ and BUN were significantly decreased after operation;MAP,SpO_2,Na~+,aldosterone and angiotensinⅡdid not change significantly after operation.
[Conclusion]Irrigation fluid's absorption was observed during mini-percutaneous nephrolithotomy.No significant changes were found in hemodynamics, fluid-electrolyte balance and hormone for those patients with normal compensation of body fluid.But some complications might take place if extension of operation time, loss of tunnel,perforation of renal pelvis,renal parenchyma and ureter exist during mini-percutaneous nephrolithotomy.These complications might lead to irrigation fluid absorption syndrome.Therefore,the monitoring of hemodynamics, fluid-electrolyte balance and hormone,especially hemodynamics,was very important to discover irrigation fluid absorption syndrome in time.
引文
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[2]王刚.经皮肾镜技术[J].CHINA MEDICAL NEWS,2004,19(4):21.
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[23]Gofrit ON,Shapiro A,Donchin Y,et al.Lateral decubitus position for percutaneous nephrolithotripsy in the morbidly obese or kyphotic patient[J].J Endourol,2002,16(6):383-386.
[24]Auge BK,Lallas CD,Pietrow PK,et al.In vitro comparison of standard ultrasound and pneumatic lithotrites with a new combination intracorporeal lithotripsy device[J].Urology,2002,60(1):28-32.
[25]Wong C,Leveillee RJ.Single upper pole percutaneous access for treatment of＞or=5cm complex branched staghorn calculi:is shock wave lithotripsy necessary?[J].J Endourol,2002,16(7):477-481.
[26]李逊.经皮肾穿刺取石术治疗上尿路结石(20年经验)[J].北京大学学报(医学版),2004,36(2):124-126.
[27]Monga M,Oglevie S.Minipercutaneous nephorlithotomy[J].J Endourol.2000,14(5):419-421.
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[30]李炯明,徐鸿毅,刘建和,等.微创经皮肾镜气压弹道碎石术治疗上尿路结石(附706例报告)[J].临床泌尿外科杂志,2006,21(2):137-138.
[31]刘建和,李炯明,陈戬,等.微通道经皮肾镜治疗肾下盏结石79例报告[J].临床泌尿外科杂志,2006,21(11):126-127.
[32]Glenn M,Dean G,James E,et al.AUA Guideline on the Management of Staghorn Calculi[M].AUA Education and Research,2005:1-6.
[33]Walsh.Campbell's Urology[M].8th ed.Elsevier Science,2002:3416-3432.
[2]那彦群主编.2007版中国泌尿外科疾病诊断治疗指南[M].北京:人民卫生出版社,2007:168.
[3]Glenn M,Dean G,James E,et al.AUA Guideline on the Management of Staghom Calculi[M].AUA Education and Research,2005:1-6.
[4]Walsh.Campbell's Urology[M].8th ed.Elsevier Science,2002:3416-3432.
[5]王刚.经皮肾镜技术[J].CHINA MEDICAL NEWS,2004,19(4):21.
[6]李逊.经皮肾镜术[J].临床泌尿外科杂志,1996,11(6):365-367.
[7]曾国华,李逊,吴开俊,等.微创经皮肾镜取石术治疗输尿管上段结石[J].中华泌尿外科杂志,2003,10:671.
[8]单炽昌.经皮肾镜取石术在治疗上尿路结石中的应用[J].实用医学杂志,2002,18(6):566-567.
[9]李炯明,徐鸿毅,刘建和,等.微创经皮肾镜气压弹道碎石术治疗上尿路结石(附706例报告)[J].临床泌尿外科杂志,2006,21(2):137-138.
[10]刘建和,李炯明,陈戬,等.微通道经皮肾镜治疗肾下盏结石79例报告[J].临床泌尿外科杂志,2006,21(11):126-127.
[11]Jackman SV,Docimo SG,Cadeddu JA,et al.The mini-perc technique:a less invasive alternative to percutaneous nephrolithotomy[J].World J Urol,1998,16:371-374.
[12]Hahn RG.Ethanol monitoring of irrigating fluid absorption[J].European of Journal of Anaesthesioligy,1996,13:102-105.
[13]Malhotra SK,Khaitan A,Goswami AK,et al.Monitoring of irrigation fluid absorption during percutaneous nephrolithotripsy:the use of 1%ethanol as a marker[J].Anaesthesia,2001,56(11):1103-1106.
[14]Koroglu A,Togal T,Cicek M,et al.The effects of irrigation fluid volume and irrigation time on fluid electrolyte balance mad hemodynamics in percutaneous nephrolithotripsy[J].Int Urol Nephrot 2003,35(1):1-6.
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