急性高容血液稀释加术中血液回收对骨科患者的影响

欧珊，周乐顺，白树荣等.急性高容血液稀释加术中血液回收对骨科患者的影响[J].中华创伤杂志.2013, 29(3):273-276

血液稀释,肾循环,术中血液回收

欧珊，周乐顺，白树荣，巩固，林露，李军，潘显明

610083,成都军区总医院麻醉科; 610083,成都军区总医院骨科

2013

273-276

万方

目的 评价万汶[体积分数6％羟乙基淀粉氯化钠溶液(HES)]用于急性高容血液稀释(acute hypervolemic hemodilution,AHH)加术中血液回收(intra-operative cell salvage,ICS)对骨科手术患者血流动力学、节血效能和肾功能的影响. 方法 选择58例骨科手术患者作为研究对象,按随机数字表法分为AHH+ ICS组(30例)和对照组(28例).比较AHH+ ICS组和对照组术前(TO)、手术结束时(T1)、术后4 h(T2)、术后1 d(T3)及术后2 d(T4)血流动力学指标心率(HR)、平均动脉压(MAP)、中心静脉压(CVP)的变化,肾功能指标血尿素氮(BUN)、血肌酐(BCr)、尿肌酐(UCr)和尿白蛋白(ALB)的变化,计算肌酐清除率(CCr)并观察术中血液保护情况.结果 两组间HR、MAP、CVP差异无统计学意义.两组T1 ～ T4时相点,HR与TO时相点比较有一定程度降低(P＜0.05),MAP及CVP与TO时相关比较均有上升(P＜0.05).两组BUN、BCr和ALB各时相点组间及组内比较,差异均无统计学意义.CCr分析结果显示:对照组各时相点差异无统计学意义；AHH+ICS组T1～T4时相点与TO时相点比较均有一定程度降低,T2时相点最低(P＜0.01),T3～T4时相点回升,T4时相点虽仍低于TO时相点但差异无统计学意义；AHH+ ICS组与对照组TO时相点比较差异无统计学意义,T1 ～ T4时相点,AHH+ ICS组均低于对照组,T2时相点最明显(P＜0.01),至T4时相点差异仍有统计学意义(P＜0.05).两组各时相点肾功能指标均在正常范围内.AHH+ ICS组及对照组术中失血量和尿量差异无统计学意义,术中补液量、异体血输注量及输注比例AHH+ ICS组明显少于对照组(P＜0.05或P＜0.01). 结论 采用万汶行AHH+ ICS用于骨科手术患者,能明显减少术中异体血输注量和输注比例,对基本生命体征和肾功能均无明显影响,是安全、有效、值得推广的综合血液保护措施.但在大剂量、长时间使用HES时仍应注意其可能的潜在肾功能损伤,对术前有严重肾功能障碍者应谨慎使用. Objective To evaluate impacts of acute hypervolemic hemodilution (AHH) and intra-operative cell salvage (ICS) with 6％ volume fraction of hydroxyethyl starch (HES) on hemodynamics,blood saving efficiency and renal function of orthopedic surgery patients.Methods A total of 58 patients from orthopedic surgery were involved and randomly divided into AHH + ICS group (30 cases) and control group (28 cases).Changes of hemodynamic indices (HR,MAP and CVP) and renal function indices (BUN,BCr,UCr and ALB) in both groups were compared before operation (T0),immediately after operation (T1) and at postoperative 4 hours (T2),1 day (T3) and 2 days (T4).CCr was counted and intraoperative blood conservation was observed at each time point as well.Results HR,MAP and CVP of the two groups had no significant differences.Both groups showed some drop of HR (P ＜ 0.05),but an increase of MAP and CVP at T1-T4 (P ＜ 0.05),in contrast with levels at TO.BUN,BCr and ALB also showed insignificant differences between groups or within group at each time point.CCr in the control group showed no significant difference at each time point.On the contrary,CCr in the AHH + ICS group had a fall at T1-T4 and was declined to the lowest level at T2.CCr in the AHH + ICS group showed a recovery at T3-T4 and its level at T4 was still lower than that at TO,with no significant difference.CCr in the two groups showed insignificant difference at TO,but its level in the AHH + ICS group was lower than that in the control group at T1-T4,at T2 in particular (P ＜0.01).Moreover,CCr in the two groups was still significantly different at T4 (P ＜ 0.05).Renal function indices of the two groups were all within normal range at each time point.Intraoperative blood loss and unrine volume of the two groups had no significant differences,but intraoperative fluid requirement,allogenic blood transfusion volume and transfusion rate of AHH + ICS group were notably lower than those of control group (P ＜ 0.05 or P ＜0.01).Conclusions AHH plus ICS using HES are safe,effective and promising integrated blood conservation measures,which significantly reduces intraoperative allogenic blood transfusion volume and transfusion rate and has few impacts on fundamental vital signs and renal function.However,prolonged use of large dose of HES may do harm to renal function and therefore should be carefully considered in treatment of patients with severe renal dysfunction.