急性高容量血液稀释联合控制性降压在骨科手术病人应用的可行性

The feasibility of acute hypervolemic hemodilution combined with controlled hypotension in patients undergoing elective orthopedic operations

目的 观察急性高容量血液稀释(AHH)联合控制性降压(CH)对骨科手术病人血液动力学以及组织器官氧代谢的影响。方法 择期骨科手术病人48例，ASAⅠ～Ⅱ级，随机分为4组，每组12例：A 组为对照组；B 组为单纯 CH 组；C 组为单纯 AHH 组；D 组为 AHH 联台 CH 组。四组病人均采用全身麻醉，术中连续监测平均动脉压(MAP)、中心静脉压(CVP)、心率(HR)、心电图(ECG)、脉搏血氧饱和度(SpO_2)和尿量。分别于稀释前插管后(T_0)、稀释后(T_1)、稀释后1h(T_2)、术毕(T_3)、术后24h(T_4)采集动脉血和混和静脉血测定血红蛋白(Hb)、红细胞压积(Hct)、乳酸、混和静脉血氧饱和度(SvO_2)、动、静脉血氧含量(CaO_2、CvO_2)以及 Na^+、K^+、Ca^(2+)等变化，并计算氧摄取率(ERO_2)，术中记录输血量、输液量和失血量。结果 与 A 组比较，B、D 组失血量减少，C 组、D 组的尿量增多(P＜0.05或0.01)；与 B 组比较，C 组、D 组的尿量增多(P＜0.05)；与 C 组比较，D 组失血量减少(P＜0.05)。与T_0比较，C 组、D 组 AHH 后 CVP 升高(P＜0.01)；B 组 CH 后 HR 升高(P＜0.05)；四组间 ERO_2、K^+、Na^+、乳酸比较差异无显著性(P＞0.05)。结论 术前 AHH 联合 CH 能够维持骨科手术病人的血液动力学稳定，明显减少出血量和异体输血，并对组?

Objective To investigate the effects of acute hypervolemie hemodilution(AHH)combinedwith bypotension(CH)on hemodynamies and tissue perfusion and to evaluate the safety of the technique.MethodsForty-eight ASA Ⅰ-Ⅱ patients of both sexes(28 male,20 female)aged 41-63 yr weighing 47-85kg undergoingelective orthopedic operations were randomly divided into 4 group with 12 patients in each group:A control group;B CH group;C AHH group and D CH+AHH group.The patients were premedicated with oral diazepam 10 mgand intramuscular atropine 0.5 mg.Anesthesia was induced with midazolam 0.04 mg·kg^(-1),fentanyl 4μg·kg^(-1),propefol 1.5-2.0 mg·kg^(-1) and vecuronium 0.1 mg·kg^(-1) and maintained with inhalation of 1%-3 % isoflurane and50% N_2O in O_2 supplemented with intermittent i.v.boluses of vecaronium.The patients were mechanicallyventilated after tracheal intubation(V_T=8-10 ml·kg^(-1),RR 12 bpm).Radial artery and right internal jugular veinwere cannulated.The CVP catheter was inserted into right atrium and the blood obtained from right atrium was usedto replace mixed venous blood.ECG,MAP,HR,CVP,SpO_2 and urine output were continuously monitored duringoperation.Controlled hypotension was induced with sodium nitroprusside(NTP)at 0.1-2 μg·kg^(-1)·min^(-1) andMAP was maintained at 70% of the baseline MAP during operation.NTP infusion was terminated 30 min beforethe end of surgery.AHH was induced with 6% HES 15 ml·kg^(-1) at 50 ml·min^(-1) after induction of anesthesia andbefore skin incision.Blood samples were taken from radial artery and right atrium before AHH(T_0,baseline),immediately after AHH or before CH(T_1),1h after AHH or 40 min after start of CH(T_2),at the end of surgeryor 30 rain after termination of NTG infusion(T_3)and 24h after surgery(T_4)for blood gas analysis and calculationof oxygen extraction ratio(ERO_2).Blood volume was maintained with infusion of colloid and lactated Ringer'ssolution.The amount of blood loss and blood transfusion were recorded.Hb was maintained above 70 g·L^(-1)Results CVP increassd significantly after AHH in group C and D as compared to baseline(P<0.01);HRincreased significantly in group B after CH(P<0.01).The blood loss in group B and D was significantly lessthan that in group A(P<0.01).Urine output was significantly increased in group C and D compared with groupA and B(P<0.05).There was no significant difference in lactate,SvO_2,K^+ and Na^+ among the four groups(P>0.05).Conclusion AHH combined with CH can maintain stable hemodynamics,decrease blood loss andblood transfusion during operation and maintain the balance between oxygen delivery and oxygen consumption.