不同水平控制性低中心静脉压下肝叶切除术患者术中出血量的比较

Comparison of the effects of different levels of controlled low central venous pressure on blood loss in patients undergoing hepatic lobectomy

目的比较不同水平控制性低中心静脉压（CVP）对肝叶切除术患者术中出血量的影响。方法择期全麻下拟行肝叶切除术患者100例，年龄28～78岁，体重39—90kg，ASA分级I或Ⅱ级，采用随机数字表法分为5组（n=20）：CVP。组患者肝叶切除时CVP分别控制在1、2、3、4和5mmHg，在肝叶切除术期间通过限制输液、利尿或使用血管活性药物等方法维持CVP在各组要求的水平。记录各组肝实质离断前、离断过程中及完全离断后的出血量（V1-2），测定肝实质横截面积（TA），计算肝实质单位横截面积出血量（VTA），记录上述3个时段患者输液、输血情况。于术前、肝实质离断5min及术毕时记录MAP和HR。结果与CVP5组比较，CVP1-2组肝实质离断过程中MAP降低，CVP1-3组V2和VTA降低，CVP1-4组术中未输血比例升高，肝实质离断完成前输液量降低（P〈0．05）；与CVP4组比较，CVP2组V2和VTA、肝实质离断过程中MAP降低，CVP1组肝实质离断完成前输液量升高（P〈0．05）。结论肝叶切除术时CVP控制在3mmHg的患者血液动力学平稳且术中出血量少。

Objective To compare the effects of different levels of controlled low central venous pressure （CVP） on blood loss in patients undergoing hepatic lobectomy. Methods One hundred ASA Ⅰ - Ⅱ patients, aged 28-78 yr, weighing 39-90 kg, undergoing elective hepatic lobectomy under general anesthesia, were randomly di- vided into 5 groups （ n = 20 each） with CVP controlled at 1, 2, 3, 4 and 5 mm Hg during the course of operation respectively （groups CVP1-5 ）. Anesthesia was induced with midazolam, fentanyl, etomidate and vecuronium. The patients were tracheal intubated and mechanically ventilated. Anesthesia was maintained with iv infusion of propofol and remifentanil, inhalation of isoflurane and intermittent iv boluses of vecuronium. CVP was maintained at the predetermined levels by restricted infusion or by administration of diuretics or vasoactive agents and so on during operation. The blood loss before, during and after removal of the diseased liver parenchyma （V1-3） was recorded. The liver parenchyma transection area （TA） was determined and the blood loss per transection area （VTA） was calculated. Fluid infusion and blood transfusion were recorded during the three time periods mentioned above. MAP and HR were recorded before operation, at 5 min after removal of the diseased liver parenchyma was started and at the end of operation. Results Compared with group CVP5 , the MAP during removal of the diseased liver parenchyma in groups CVP1,2, V2 and VTA in groups CVP1-3, and the percentage of patients who needed blood transfusion during operation and the amount of fluid infused before completion of removal of the diseased liver parenchyma in groups CVP1-4 were significantly decreased （P 〈 0.05）. Compared with group CVP4, V2, VTA and MAP during removal of the diseased liver parenchyma were significantly decreased in group CVP2 and the amount of fluid infused was significantly increased before removal of the diseased liver parenchyma was completed in group CVP1 （ P 〈 0.05）. Conclusion When CVP is controlled at 3 mm Hg, the hemodynamics is stable and blood loss is less during hepatic lobectomy.