微通道和标准通道经皮肾镜碎石术对上尿路结石患者血流动力学和血气分析的影响

Effects of Microchannel and Standard Percutaneous Nephrostolithotomy on Hemodynamics and Blood Gas Analysis in Patients with Upper Urinary Tract Calculi

目的观察微通道经皮肾镜碎石术(PCNL)和标准通道PCNL对上尿路结石患者血流动力学和血气分析的影响。方法选取2012年1月—2013年11月重庆三峡中心医院肾结石患者200例,采用随机数字表分为微通道PCNL组和标准通道PCNL组,各100例。在PCNL术中,微通道PCNL组推入F16塑料薄鞘建立经皮肾通道;标准通道PCNL组推入F24塑料薄鞘建立经皮肾通道。记录两组患者麻醉前,灌流前,灌流10、30、60、90、120 min及术后患者平均动脉压(MAP)、心率(HR)、中心静脉压(CVP);手术结束时记录灌流量和手术时间;检查血常规、静脉电解质和动脉血气分析〔包括Na+、Cl-、K+、p H、碱剩余(BE)〕。结果微通道PCNL组手术时间为(102.3±19.1)min,高于标准通道PCNL组的(83.8±15.2)min(t=7.58,P<0.05);微通道PCNL组灌流液量为(21.0±1.3)L,高于标准通道PCNL组的(15.6±2.0)L(t=22.64,P<0.05)。生命体征组间比较显示:两组HR、MAP和CVP在不同时间点比较,差异均无统计学意义(P>0.05)。组内比较显示:两组HR不同时间点比较,差异无统计学意义(P>0.05);两组灌流前MAP和CVP均低于麻醉前(P<0.05);MAP和CVP在灌流10 min与灌流前比较,差异均无统计学意义(P>0.05);在灌流30、60、90、120 min及术后均高于灌流前(P<0.05)。动脉血气分析组间比较显示:两组Na+、Cl-、K+、p H、BE在不同时间点比较,差异均无统计学意义(P>0.05)。组内比较显示:两组术后Na+、Cl-与麻醉前比较,差异无统计学意义(P>0.05)。两组术后K+、p H、BE均低于麻醉前(P<0.01)。两组患者术后均无尿脓毒症及其他严重并发症发生。结论随着手术时间增加,灌流液的吸收对血流动力学和动脉血气分析的影响逐渐增加;对于心、肺、肾功能正常的患者,由于器官功能的代偿,微通道PCNL与标准通道PCNL引起的灌流液吸收量的差异不足以引起患者血流动力学和血气分析的不同。

Objective To explore the effects of percutaneous nephrostolithotomy（PCNL） and microchannel PCNL （mPCNL） on hemodynamics and blood gas analysis（ BGA） in patients with upper urinary tract calculi. Methods From january 2012 to November 2013,200 kidney stone patients from Three Gorges Central Hospital were randomized into groups PCNL,mPCNL,100 in each. The mPCNL group were injected with F16 plastic sheath,PCNL group with F24 plastic sheath to establish percutaneous renal access. Patientsˊ mean arterial pressure（ MAP）,heart rate（ HR）,central venous pressure （CVP）before anesthesia,before perfusion,at minutes 10,30,60,90,120 of perfusion and after operations were recorded and blood routine examination, venous electrolyte, BGA including Na ＋ , Cl - , K ＋ , pH, base excess （ BE ） were determined. Results The surgical time of mPCNL group was（102. 3 ± 19. 1）min,higher than that of PCNL group〔（83. 8 ± 15. 2）min〕（t = 7. 58,P 〈 0. 05）;the perfusion liquid measure of mPCNL group was（21. 0 ± 1. 3）L,higher than that of PCNL〔（15. 6 ± 2. 0）L〕（t = 22. 64,P 〈 0. 05）. In group comparison,there was no significant difference in HR,MAP, CVP between 2 groups at different time points（P 〉 0. 05）,MAP,CVP lower before perfusion than before anesthesia in 2 groups （P 〈 0. 05）. MAP,CVP at 10 min of perfusion were not different from those before perfusion（ P 〉 0. 05）,but higher at minutes 30,60,90,120 than before perfusion（P 〈 0. 05）. In intra - group comparison,there was no difference in Na ＋ , Cl - between postoperation and pre - anesthesia in 2 groups（ P 〉 0. 05）,K ＋ ,pH,BE lower after operation than before anesthesia（P 〈 0. 01）. No urosepsis or other severe complications were found in 2 groups after operation. Conclusion With the increase of operative time,the effects of the absorption of perfusate on hemodynamics and BGA increase. For the patients with normal functions of heart,lung and total kidney,the difference of absorption of perfusate caused by mPCNL and PCNL is insufficient to lead the difference of hemodynamics and BGA.