柱手术患者急性高容量血液稀释联合制性降压及自体血液回收的效应

Blood-saving effect of acute hypervolenlic hemodilution combined with controlled hypotension and blood salvage in patients undergoing spine surgery

目的评价脊柱手术患者急性高容量血液稀释（AHH）联合控制性降压及白体血液回收的效应。方法择期行脊柱手术患者30例，随机分为2组（n=15）：控制性降压联合自体血液回收组（I组）和AHH联合控制性降压及自体血液回收组（Ⅱ组），Ⅱ组手术前输注6％羟乙基淀粉130／0．4（10ml/kg）和复方乳酸钠林格氏液10ml／kg，速率为30ml／min。2组均在手术开始后静脉输注尼卡地平行控制性降压，速率为1．0～6．0μg·kg^-1·min^-1，在10～15min使MAP降至65～70mmHg，直至脊柱内固定安器安装完毕。2组术中均行自体血液回收，于脊柱内固定器安装完毕后回输。术中持续监测血液动力学参数．记录术中异体输血情况、尿量及术后引流量、异体输血量、不良反应的发生情况。结果2组术中HR和CVP均保持稳定。与l组比较，Ⅱ组术中异体输血免除率升高，异体输血量减少（P〈0．01），术中回收血量差异无统计学意义（P〉0．05），尿量增多（P〈0．01），术后引流量、异体输血量差异无统计学意义（P〉0．05）。2组均未见心、脑、肾功能异常的发生。结论脊柱手术患者AHH联合控制性降压及自体血液回收可减免异体输血。

Objective To evaluate the blood-saving effect of acute hypervolemic hemodilution （AHH） combined with controlled hypotension （CH） and blood salvage （BS） in patients undergoing spine surgery. Methods Thirty ASA Ⅰ or Ⅱ patients of both sexes aged 25-55 yr weighing 45-75 kg undergoing spine surgery were included in this study. Their Hb was ≥ 120 g/L, platelet count i〉 100 × 10^9/L and Hct≥35%. The patients were premedicated with intramuscular phenobarbital 0.1 g and atropine 0.5 mg. Anesthesia was induced with midazolam 0.05 mg/kg, fentanyl 3.0-4.0 μg/kg, etomidate 0.3 mg/kg and atracufium 0.6-0.7 mg/kg and maintained with infusion of propofol at 3-4 mg·kg^-1· h^-1 and remifentanil at 0.12-0.15 μg·kg^-1·min^-1 and intermittent iv boluses of atracufium. The patients were intubated and mechanically ventilated. The patients were randomly divided into 2 groups （n = 15 each）： groupⅠ CH ＋ BS and groupⅡ AHH ＋ CH ＋ BS. CH was induced by infusion of nicardipine at 1.0-6.0 μg·kg^-1·min^-1 after operation was started until internal fixation of the spine was completed. MAP was maintained at 65-70 mm Hg and the blood shed during operation was salvaged with cell saver in both groups. AHH was induced with 6% HES 130/0.4 10 ml/kg and lactated Ringer＇s solution 10 ml/kg infused at 30 ml/min before operation in group Ⅱ . 6% HES 130/0.4 and lactated Ringer＇s solution （1：2） were infused during operation based on CVP and urine output. If blood loss 〉 25% of blood volume and Hct 〈 25% after the salvaged blood was infnsed, concentrated RBC was infused. Hemodynamics, the amount of banked blood infused, urine output and adverse reactions were recorded. Results The two groups were comparable with respect to M/F sex ratio, age, body weight and height, preoperative Hb, Hct, PLT count and operation time. HR and CVP were kept stable in both groups. The percentage of the patients without allogeneic blood transfusion was significantly increased, volume of banked blood infused was significantly decreased while urine output was increased in group Ⅱ as compared with group Ⅰ. There was no significant difference in postoperative blood loss and allogeneic blood transfusion between the two groups. There was no adverse effect in either grouP. Conclusion AHH combined with CH and BS can significantly reduce allogeneic blood transfusion during the operation on the spine.