不同血红蛋白输血指征对中老年肿瘤手术患者的影响

The influence of two transfusion triggers on middle-and old-aged patients during tumorectomy

目的探讨应用不同输血指征管理对中老年消化道肿瘤手术患者的影响。方法选择ASAⅠ—Ⅱ级、年龄45—72岁消化道恶性肿瘤患者80名,随机数字法均分为Ⅰ组:输血指征为Hb 100 g/L;Ⅱ组:输血指征为Hb80 g/L。患者入手术室后常规使用静脉复合气管内吸入麻醉,分别于麻醉前、肿瘤切除后、术毕、术后24 h和出院时测定血常规、血乳酸含量、动脉血气,并记录术中总输血、输液量、输血并发症。结果1)血常规:在肿瘤切除后至手术后24 h,Hb 80 g/L组(Ⅱ组)患者Hb[(89±4.6)g/L]明显低于Hb 100 g/L组[Ⅰ组,(109±5.1)g/L],但在出院时,Ⅰ、Ⅱ组Hb分别为(127±8.3)g/L和(128±6.0)g/L(P>0.05);2)血乳酸浓度:肿瘤切除后2组患者分别从术前的(1.03±0.10)、(1.00±0.08)mmol/L升高为(1.90±0.15)和(1.85±0.19)mmol/L,并持续至出院(P<0.05)。3)动脉血气和血流动力学:2组患者在麻醉前、术后24 h和出院时,动脉氧分压(PaO2):Ⅰ组分别为(82.4±3.8)、(82.3±4.2)、(81.9±3.0)mmHg,Ⅱ组分别为(82.6±3.9)、(80.7±3.3)、(81.8±3.3)mmHg;动脉CO2分压(PaCO2):Ⅰ组分别为(41.0±1.5)、(41.4±2.0)、(41.7±1.5),Ⅱ组分别为(41.3±1.8)、(41.7±1.5)、(41.5±1.6)mmHg;血液pH:Ⅰ组分别为7.41±0.02、7.41±0.01、7.41±0.02,Ⅱ组分别为7.41±0.02、7.42±0.02、7.41±0.02;4)输血和相关并发症等:观察过程中患者无一例死亡。Ⅱ组患者输入浓缩红细胞的比例(22.5%)和输血量[(0.40±0.77)U/例]均显著低于Ⅰ组(分别为47.5%和(0.93±1.00)U/例,P<0.01),但2组患者输液量、输血并发症发生率、术后切口感染率(1/40vs1/40)、延迟愈合率(1/40vs1/40)和住院时间[(11.7±1.0)dvs(11.7±1.0)d]差异无统计学意义(P>0.05)。结论无脏器功能异常合并症的中老年消化道肿瘤患者,术中将输血指征从Hb 100 g/L降至80 g/L进行管理,能满足机体代谢的需要,显著降低浓缩红细胞输入比例和输入量,同时不增加术后切口感染率及延迟愈合率,不延长患者住院时间,对节约用血有重要意义。

Objective To access the influence of two transfusion triggers during operation on the middle- and old-aged cancer patients. Methods A total of 80 patients with cancer of gastrointestinal （GI） tract, ASA Ⅰ--Ⅱ and aged from 45 to 72 years, were divided into two groups with intraoperative transfusion trigger of hemoglobin （Hb） 100g/L in group Ⅰ , and Hb 80g/L in group Ⅱ. Anesthesia was performed with intravenous injection combined with tracheal inhalation. Blood routine examination, plasma lactic acid levels, and arterial blood gases were tested. Blood transfusion, fluid infusions and complication of blood transfusion were also observed. Results 1 ） Hb levels were significantly lower in group Ⅱ [ （89 ± 4. 6）g/L and（88 ±6.4）g/L] than in group Ⅰ [（109 ±5.1）g/L and（106 ±6.9）g/L] during and 24h after operation. They were, however, similar at discharge [Group Ⅰ ：（127 ±8.3）g/L vs. Group Ⅱ ： （128±6.0）g/L, P〉0.05]. 2） Blood lactic acid levels increased after operation in both group [ Group Ⅰ ： （ 1.90 ±0. 15） mmol/L and Group Ⅱ ： （ Ⅰ. 85 ± 0. 19） mmol/L] compared with before anesthesia [Group Ⅰ ： （ 1.03 ±0. 10） mmol/L and Group Ⅱ ： （ 1.00 ±0.08） mmol/ L, P 〈 0. 01 ] , and they were significantly lower in group Ⅱ than in group Ⅰ during and 24 h after operation （ P 〈 0. 05 ）. 3 ） Before anesthesia, 24 h after operation and at discharge, arterial blood gas were as follows： arterial oxygen pressures （ PaO2 ） were （ 82.4 ± 3.8 ） mmHg, （ 82. 3 ± 4.2） mmHg, （ 81.9 ± 3.0 ） mmHg respectively in group Ⅰ , and （ 82.6± 3.9）mmHg, （80. 7 ±23.3） mmHg, （81.8±3.3） mmHg respectively in group Ⅱ ; arterial CO2 pressures were （41.0 ± 1.5 ）mmHg,（41.4±2.0） mmHg,（41.7 ± 1.5） mmHg respectively in Group Ⅰ , and（41.3 ±1.8） mmHg,（41.7 ± 1.5） mmHg, （41.5 ± 1.6） mmHg respectively in group Ⅱ ; blood pH were 7.41 ±0. 02,7.41 ± 0. 01, and 7.41 ± 0. 02 respectively in group Ⅰ , and 7.41 ±0. 02,7.42 ±0.02,7.41±0. 02 respectively in group Ⅱ. 4） No death occured during the study. Blood transfusion were significantly higher in group Ⅰ [47.5% and （0. 93 ± 1.00）U/per patient] than these in group Ⅱ [22. 5% and （0.40 ±0. 77）U/per patient, P 〈0.05]. But we failed to find any differences in the amount of fluid infusion and the incidence of transfusion complications （group Ⅰ ： Group Ⅱ = 1/40 ： 1/40 of wound infection and 1/40 vs 1/40 of prolonged wound healing） between the two groups （P 〉0. 05）. There was also no difference in hospitalization days between group Ⅰ [ （ 11.7 ±1.0） days ] and group Ⅱ [ （ 11.7 ± 1.0） days, P 〉 0. 05 ]. Conclusion To the middle- and old-aged GI cancer patients without organ dysfunction, lowering blood transfusion trigger from Hb 100 g/L to Hb 80 g/L during operation can meet the requirement of oxygen, reduce blood transfusion, and do not increase the rates of wound infection or delay wound healing.