临床常用液体离体血液稀释对凝血功能的影响

Effects of hemodilution with different fluids on blood coagulation in vitro

目的应用血栓弹力描记图(TEG)研究临床麻醉和手术过程中常用液体行离体血液稀释后凝血功能的变化。方法选取12名健康志愿者,采集外周静脉血后分别应用0.9%氯化钠溶液(NS)、乳酸钠林格注射液(RL)、琥珀酰明胶注射液(GEL)、聚明胶肽注射液(PI)、羟乙基淀粉130/0.4氯化钠注射液(HES130/0.4)、羟乙基淀粉200/0.5氯化钠注射液(HES200/0.5)、高渗氯化钠羟乙基淀粉40溶液(HM),均以10∶0(不稀释)、10∶2、10∶4和10∶6的稀释度(DR)进行血液稀释,观察不同液体在不同DR条件下TEG指标的变化,TEG指标包括反应时间(R)、血凝块形成时间(K)、α角(α)、最大振辐(MA)。结果 NS稀释后,不同DR情况下TEG各指标的差异均无统计学意义(P值均>0.05)。RL以10∶2和10∶4稀释后,R值和K值逐渐缩短,α值升高,DR为10∶4时与DR为10∶0时间3项指标的差异有统计学意义(P值均<0.05),表明此时血液凝固呈高凝趋势;DR为10∶6时上述高凝现象得到缓解,且MA值显著低于DR为10∶0时(P<0.05)。随着GEL和PI的DR加大,R值和α值有降低的趋势,K值有升高的趋势,在DR为10∶6时K值显著高于DR为10∶0时(P值均<0.05),在DR为10∶4和10∶6时MA值显著低于DR为10∶0时(P值均<0.05)。随着HES130/0.4的DR加大,R值有降低的趋势,随着HES200/0.5的DR加大,R值有升高的趋势,但差异均无统计学意义(P值均>0.05);与DR为10∶0时比较,随着HES130/0.4和HES200/0.5的DR加大,K值显著延长(P值均<0.05),α值和MA值显著降低(P值均<0.05);与DR为10∶2时比较,HES200/0.5的DR为10∶6时K值显著延长(P<0.05),α值和MA值显著降低(P值均<0.05)。随着HM的DR加大,R值和K值逐渐延长,α值和MA值逐渐降低,且不同DR间的差异均有统计学意义(P值均<0.05)。结论 NS对凝血功能无明显影响。RL的DR为10∶2和10∶4时,血液稀释后血液凝固功能增强;DR为10∶6时,血液稀释后高凝趋势得到缓解。GEL和PI对血凝块强度产生一定的影响。HES对纤维蛋白的生成和聚合略有延迟作用,在一定程度上降低血凝块的强度。HM可降低血液凝固功能,延迟纤维蛋白的生成和聚合,降低血凝块的强度。

Objective To investigate the coagulation of blood diluted with different crystalloid solutions and colloid solutions commonly used in clinical anesthesia and surgery in vitro by thrombelastograph （TEG）. Methods Blood samples were obtained from 12 healthy adult volunteers, and were diluted with 0.9% normal saline （group NaCI）, Lactated Ringer＇s solution （group RL）, succinylated gelatin injection （group GEL）, polygeline （group polygeline）, 6% hydroxyethyl starch 130/0.4 （group HES130/0.4）, 6% hydroxyethyl starch 200/0.5 （group HES200/0.5） or hypertonic sodium chloride hydroxyethy starch 40 （group HM）. The dilution ratios of citrated blood volume to fluid volume were 10 ： 0 （undiluted）, 10 ： 2, 10 ： 4 and 10 ： 6, respectively. TEG parameters, including reaction time, coagulation time, growth angle and maximum amplitude were recorded. Results TEG parameters had no significant change when blood samples were diluted with different dilution ratios of NaCI （all P〉0.05）. In group RL, reaction time and coagulation time began to shorten and growth angle became larger when the dilution ratio was 10：2, and the above-mentioned three parameters at the dilution ratio of 10 ： 4 were significantly different from those at 10：0 （all P〈0.05）. It indicated that hypercoagulability appeared at the dilution of 10：4. Nevertheless, at the dilution ratio of 10：6, the hypercoagulability was alleviated and maximum amplitude was significantly decreased as compared with the undiluted one （P 〈 0. 05 ）. In group GEL and polygeline, reaction time and growth angle were gradually decreased, while coagulation time was gradually increased; coagulation time at the ratio of 10：6 was significantly higher than that at 10：0 （P〈0.05）; maximum amplitudes at the ratio of 10：6 and 10：4 were significantly lower than that at 10：0 （both P〈0.05）. Significantly decreased growth angle and maximum amplitude and prolonged coagulation time were observed in group HES130/ 0.4, HES200/0.5 and HM （all P〈0.05）, and significantly prolonged reaction time was noticed in group HM. Conclusion Normal saline does not impair hemostasis. Lactated Ringer leads to hypercoagulability at the dilution ratio of 10 ： 2 and 10 ： 4; however, the hypercoagulability decreases at 10 ： 6 dilution ratio. Succinylated gelatin and polygeline can reduce clot firmness. Both HES and HM can delay initial fibrin formation, disturb fibrin buildup and reduce clot firmnes. Additionally, HM can reduce the activity of coagulation factors. （Shanghai Med J, 2014, 37： 292-296）