参附改善心脏直视手术凝血-纤溶动态平衡的作用

Injection Shenfu (参附注射液) ameliorate the coagulation-fibrinolysis dynamic equilibrium in open heart surgery

目的:探讨将参附注射液(SFI)用于体外循环(CPB)对二尖瓣置换术(MVR)围术期凝血-纤溶功能的影响。方法:择期MVR患者40例随机分为对照组(C组),全过程都不用SFI;Ⅰ、Ⅱ实验组:预充时经CPB分别泵入SFI 1.0ml/kg或1.5ml/kg;Ⅲ组开放主动脉时经CPB泵入SFI 1.5ml/kg;Ⅳ组分别于预充和开放主动脉时经CPB泵入SFI 1.5ml/kg。各组从中心静脉采血测定ACT、PT、APTT及血浆D-D含量,应用凝血-纤溶动态图仪(CFD-Ⅲ型)检测凝固启动时间(CST)、最大凝固程度(MCE)、凝固峰值时间(MCT)、平衡时间(BLT)及完全纤溶时间(WFT),作凝血-纤溶动态平衡分析。记录术后心包和纵隔引流量(胸引量)及引流拔管时间。结果(1)血浆D-D含量:各组术毕(T2)、术后3h(T3)较术前(T1)明显增高(P<0.05),术后24h(T4)时降低;与C组比较,Ⅳ组明显较低(P<0.05)。(2)凝血-纤溶动态平衡参数:①CST、MCT:各组T2、T3、T4均明显长于T1(P<0.01),其中,T2时CST各实验组均比C组长(P<0.05);②MCE:与T1比较,各组病人CPB后持续增高(P<0.01);③WFT:各组CPB后明显长于CPB前(P<0.01);与C组比较,T4时Ⅱ、Ⅲ、Ⅳ组明显较长(P<0.05);④BLT:各组仅T2明显长于T1(P<0.01);与C组比较,T3时Ⅲ、Ⅳ组明显较长(P<0.05)。(3)术后引流:与C组比较,Ⅳ组胸引量较少、引流拔管时间较早(P<0.05)。结论:SFI可抑制MVR后继发性纤溶活动,改善MVR后凝血-纤溶的动态平衡,减少MVR后胸引量,而对内、外源性凝血功能无明显影响。

Objective： To investigate the effect of injection Shenfu （SFI） on perioperational dynamic equilibrium of coagulation-fibrinolysis in MVR with CPB. Methods： Forty patients undergoing elective MVR were randomly assigned into controlled group （group C） and trial group Ⅰ , Ⅱ , Ⅲ, Ⅳ. Patients in controlled group accepted routine primiing fluid without SFI during CPB. In group Ⅰ andⅡ , 1.0 ml · kg^-1 SFI and 1.5 ml/kg SFI were respectively put into routine primiing fluid. Ⅲ group Ⅲ , 1.5 ml/kg SFI was pumped via CPB as soon as the clamped aorta was unclamped. In group Ⅳ, 1.5 ml/kg SFI was respectively put into routine primiing fluid and pumped via CPB as soon as the clamped aorta was undamped. And in group Ⅳ, SFⅡ 1.5 ml/kg was respectively added in routine primiing fluid and imported through CPB as soon as the clamped aorta was unclamped. Blood was drawn from central vein to determine PT, APTT, ACT in every group respectively preoperatively （ T1 ）, before the suture of skin （T2） and 3 （ T3 ）, 24 （T4） hours postoperatively. Also at these time marks the plasma content of D-dimer （D-D） was determined and the dynamic equilibrium of modified coagulation-fibrinolysis including coagulation starting time （CST） , maximum coagulation time （MCT） , maximum extent of coagulation （MCE） , whole time of fibrinolysis reaction （WFT） and balance time （BLT） was measured by coagulation-fibrinolysis dyanmicogram （CFD） instrument （ CFD-Ⅲ ）. The postoperative drainage volume from pericardium and mediastina and the time to drainage-tube＇s extubation were recorded. Results： （ 1 ） D-D： Compared with its plasma content at T1 it significantly increased at T2 and T3 （ P 〈 0.05 ） and reduced at T4. In comparison with group C, group Ⅳ had significantly lower plasma concentration of D-D （ P 〈 0.05 ）. （2） parameters of dynamic equilibrium of coagulation-fibrinolysis ： （1） CST, MCT： Both of them obviously prolonged at T2, T3 or T4 compared with them at T1 （ P 〈 0.01 ） in every group and every trial group＇s CST significantly increased （ P 〈 0. 05 ） at T2 compared with controlled group. （2） MCE： Every group＇s MCE continuously increased （P 〈 0.01 ） after CPB. The difference was significant in comparison with T1. （3） WFT： Compared with WFT before CPB it markedly prolonged after CPB （ P 〈 0.01 ） and trial group Ⅱ , Ⅲ, Ⅳ had longer WFT than controlled group at T4 （ P 〈 0.05 ）. （4） BLT ： Compared with BLT at T1 it prolonged only at T2 （ P 〈 0. 01 ） in every group but group Ⅲ or IV had longer BLT at T3 than controlled group （ P 〈 0.05 ）. （ 3 ） drainage after surgery ; Compared with controlled group, group IV had less drainage volume from pericardium and mediastina and less time to drainage-tube＇s extubation （P 〈 0. 05 ）. Conclusion： SFⅡ used during CPB can inhibit secondary fibrinolysis after MVR and consequently improve the dynamic equilibrium of coagulation-fibrinolysis and reduce the drainage volume from pericardium and mediastina but not affect endogenous or exogenous coagulation function.