体外循环稀释式自体输血5000例分析

Analysis of cardiopulmonary bypass diluted autologous blood transfusion： a report of 5000 cases

目的探讨体外循环稀释式自体输血的临床应用及经验，为节约用血提供临床依据。方法回顾郑州大学第一附属医院心外科1996年9月至2012年3月共施行的5000例完全不用库血体外循环（CPB）手术的临床资料，分析自体输血的临床应用及血液稀释深度的临床经验。术中采血后的血压，中心静脉压、心率无明显变化。围手术期血气维持于正常范围。所有患者体外循环后将体外循环机中余血和诱导后采集病人的血液全部回输，术后6h内血红蛋白（Hb）均达到90g／L以上，术后仅129例进行2次开胸止血患者因血红蛋白低于70g/L给予库血输入。结果血红蛋白（Hb），红细胞压积（Hct），酸碱值（pH），剩余碱（BE），乳酸（Lac），脑氧饱和度（rSO2），动脉血氧饱和度（SaO2）转机中与麻醉前相比P〈0．05，但除Hb和Hct外，其余指标均属围手术期正常范围内。本组死亡146例，34例死于术后低心排，48例死于脑血管意外，28例死于恶性心律失常，另有36例死于肺部感染并多器官功能障碍，总体死亡率为2．92％，其余术后均恢复顺利，无心、脑、肾等并发症的发生。结论红细胞压积（Hct）15％-19％深度血液稀释配合良好的降温和麻醉管理在体外循环中是安全可行的。鱼精蛋白体外中和体外循环前预存的肝素血是节约用血的有效方法之一。

Objective To explore the clinical application and experience of cardiopulmonary bypass （CPB） diluted autologous transfusion so as to provide clinical rationales for blood conservation. Methods At Department of Cardiothoracic Surgery, First Affiliated Hospital, Zhengzhou University, the clinical data were reviewed for 5000 CPB surgical patients without banked blood from September 1996 to March 2012 to analyze the clinical application of autologous blood transfusion and summarize the experience of depth hemodilution. No significant changes occurred in blood pressure, central venous pressure or heart rate after blood collection. The values of blood gases stayed within the normal perioperative range. The collected blood and all the remaining blood in CPB machine were reinfused to bring the postoperative level of Hb to over 90 g/L. Only 129 cases on a second thoraeotomy for hemostasis required banked blood transfusion because of hemogloblin （Hb） under 70 g/L. Results Hb, hematocrit （Hct）, pH, base excess （BE）, lactate （Lac）, cerebral oxygen saturation （rSO2） and arterial oxygen saturation （SaO2） indicated a statistically significant during CPB compared with pre-anesthetic （ P 〈 0. 05 ）. The remaining indicators stayed within the normal perioperative range except for Hb and Hct. There were 146 cases of deaths. And the causes were postoperative low cardiac output （ n = 34）, eerebrovaseular accident （ n = 48 ）, malignant arrhythmias （ n = 28 ） and lung infection and multiple organ dysfunction （n = 36）. The case fatality rate was merely 2. 92%. All survivors recovered well and no heart, brain, kidney or other complications occurred. Conclusion Hct 15% - 19% depth of hemodilution with proper cooling and anesthetic management during cardiopulmonary bypass is both safe and feasible. And neutralization heparinemia in stored blood before CPB by protamine is one of the effective methods of blood conservation.