急性高容量血液稀释结合控制性降压用于口腔颌面手术的临床研究

Acute Hypervolemic Hemodilution Combined with Controlled Hypotension Using on Patient Undergoing Elective Oral and Maxillofacial Operation

目的：观察急性高容量血液稀释（AHH）结合控制降压（CH）对口腔颌面外科手衍病人血流动力学及组织器官氧代谢的影响。方法：选择择期口腔颌面外科病人60例，ASAⅠ～Ⅱ级，随机分为三组，每组20例，A组为封照组，B组为单纯组AHH组，C组为AHH＋CH组。三组都在全身麻醉下手术，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（SpO2）和尿量；稀释前插管后（H0）、稀释后（H1）、稀释后1h（H2）、术毕（H3）、衍后24h（H4）5个时同点，分别采集动脉血和静脉血，测定血红蛋白（Hb）、红细胞压积（Hct）、乳酸、静脉血氧饱和度（STO2），动脉血氧含量（CaO2）、静脉血氧含量（CVO2）以及血Na^＋K^＋Ca^2＋，计算氧摄取率（ERQ）；术中记绿输血量，输液量、失血量和尿量。结果：与A组比较，B、C两组失血量减少（P〈0．05）；B组、C组尿量增多（P〈0．01）；与B组比较，C组失血量显著性减少（P〈0．05）。与稀释前比较，B组和C组AHH后CVP都升高，B组比C组更为显著（P〈0．01）。C组在CH后HR升高（P〈0．05）。三组同ERO2、K^＋、Na^＋、乳酸比较，无显著性差异（P〉0．05）。结论：术前施行AHH结合CH用于口腔颌面大手术病人，可保持血液动力学稳定．出血量和输血量明显减少，氧代谢无明显影响。

Objective To investigate the effects of acute hypervolemic hemodilution （AHH） combined with controlled hypotension （CH） on hemodynamics and tissue perfusion and to evaluate it＇s security. Methods Sixty cases with ASA Ⅰ-Ⅱ grade, aged 21-56yr, weighing 36-80kg, undergoing elective oral and maxillofacial operation were randomly divided into 3 group with 20 cases in each group： Control group（ group A ） ; AHH group（ group B ） and CH＋AHH group （ group C ）. The anesthesia was induced by propofol 2. 5mg / kg, fentanyl 5-6μg/kg and pavulon 0. 1mg/kg Ⅳ and was maintained with 1%-3%isoflurane inhale and fentanyl, propofol, pavulon or vecuronium with intermittent Ⅳ. The parameters of ECG, MAP,HR,CVP, SpO2 and urine output were continuously monitored and recorded. AHH was induced with RL and 6%HES （10 ： 5） 15ml/kg at 50ml/min after induction of anesthesia and before skin incision. Controlled hypotension was induced with sodium nitroprusside intravenous infused at 0. 2-6μg/（kg · min） and kept at 70% of the baseline MAP during operation, and was terminated 60min before the end of operation. Blood samples were taken from radial artery and right atrum before AHH（H0）, immediately after AHH or before CH（H1 ）, lh after AHH（H2）, at the end of surgery （Ha） and 24h after surgery（H4） for the measurement of blood gas analysis and the calculation of oxygen extraction ration （CERO2）. The blood volume was maintained with infusion of colloid and lactated Ringer＇s solution. The amount of blood loss and blood transfusion were recorded, Hb was maintained above 80g /L. Results CVP increased significantly after AHH in group B as compared to baseline（P〈0.01）, HR increased significantly in group C after CH （P〈0.05）. The blood loss in group B and group C were signif .cantly less than that in group A （P〈0. 05 and P〈0.01）. The urine output was significantly increased in group B and group C compared with group A（P〈0. 05）. There were no signifi- cant difference in lactate, SVO2, K^＋ and Na^＋ among the three groups （P〉0.05）. Conclusion AHH com- bined with CH can maintain stable hemodynamics, decrease the volume of blood loss and blood transfusion during operation and maintain the balance between oxygen delivery and oxygen consumption.