急性非等容量血液稀释对硬膜外阻滞复合全麻手术患者循环和凝血功能的影响

Effects of Acute Non-isovolemic Hemodilution on Hemodynamics and Blood Coagulation of Patients with Epidural Anesthesia Combined with General Anesthesia

目的观察术前急性非等容量血液稀释(ANIH)对硬膜外阻滞复合全身麻醉(EA/GA)手术患者血流动力学和凝血功能的影响,评价其安全性和有效性。方法60例ASAⅠ～Ⅱ级择期上腹部手术患者,随机分为ANIH组(A组)和对照组(C组),每组30例,均在EA/GA下施术。A组于硬膜外阻滞后全麻诱导前采取循环血量10%～15%的全血(400～600mL),然后快速(30mL/min)输注乳酸钠林格氏液(10mL/kg)和6%羟乙基淀粉液(20mL/kg)行ANIH;C组单纯输注乳酸钠林格氏液(10mL/kg)补充生理需要量。术中监测平均动脉压(MAP)、心率(HR)、中心静脉压(CVP)、心排血量(CO)、外周循环阻力(SVR)及动脉血乳酸浓度(LAC);分别于稀释前、稀释后、术毕、术后第1天和第7天测定红细胞压积(Hct)、凝血酶原时间(PT)、活化部分凝血活酶时间(APTT)和纤维蛋白原浓度(FIB)的变化,记录术中输血量、输液量、尿量和麻黄碱用量,并计算出血量。结果两组患者术中出血量和尿量无明显差异(P>0.05);输血量、输液量及麻黄碱用量C组明显高于A组(P<0.05)。术中A组MAP较稳定,而C组下降明显(P<0.05)。稀释后,A组CO和CVP升高而SVR和Hct则降低,与基础值及C组相比差异明显(P<0.05),Hct在术后第1天和第7天两组无明显差异(P>0.05);PT、APTT和LAC在稀释前后变化不明显(P>0.05),FIB虽呈稀释性下降,但术后第1天基本恢复正常。结论ANIH对凝血功能无明显影响,可增强EA/GA手术患者循环功能的稳定性,有效减少围术期异体输血。

Objective To investigate the effects of acute non-isovolemic hemodilution（ANIH） on hemodynamics and blood coagulation of patients with epidural anesthesia combined with general anesthesia（EA/GA）and evaluate its safety and effecttiveness. Methods Sixty ASAⅠ-Ⅱ patients with EA/GA undergoing upper abdominal surgery were randomly divided into two groups. In group A（ANIH）400-600 mL of blood（about 10% - 15% of BV）was removed and then infused with Lactated Ringer＇s Sodium（10 mL/kg）and 6% hydroxyethyl starch（20 mL/kg）at a rate of 30 mL/min before induction and after epidural anesthesia. Group C was infused with Lactated Ringer＇s Sodium（10 mL/kg）at same time. MAP, HR, CO, SVR and LAC were monitored during the operation. Hct, PT, APTT and FIB were measured before and after hemodilution, the end of operation,and 1 d,7 d after operation. The volume of urine and infusion and blood loss and blood transfusion were recorded. Results There was no significant difference in PT,APTT and LAC before and after hemodilution between two groups（P〉0.05）. During the surgery,the volume of urine and blood loss was similar to that in group C,but the volume of infusion and blood transfusion and dose of ephedrine in group A were significantly less than that in group C. Following hemodilution in group A, the CO and CVP were obviously higher than that in group C and basal value（P〈0.05） ,and SVR decreased obviously（P〈0.05）. The MAP less changed in group A, Hct and FIB decreased markedly after hemodilution and during the operation（P〈0.05）,but without significant difference in first and seventh postoperative day between two groups（P〉0. 05）. Conclusion ANIH has no significant effect on biood coagulation and could be safely used on patients with EA/GA and obviously improve the stablization of circulatory function.