急性等容血液稀释采自体血回输联合控制性降压对异体输血及凝血功能的影响

Effect of Acute Normovolemic Hemodilution with Autologous Blood Transfusion and Controlled Hypotension during Surgery on Allogeneic Blood Transfusion and Blood Coagulation Function

目的 在手术中应用急性等容血液稀释（ANH）采自体血回输联合控制性降压（CH）的方法，以观察节约血液的效果及该技术对凝血功能的影响。方法 选择 2012 年 2 月－ 2014 年 1 月预计出血量＞ 400 mL 的Ⅲ～Ⅳ级手术患者 60 例，用随机数字表法将患者随机分为 ANH＋CH 组和对照组，各 30 例。ANH＋CH 组气管插管全身麻醉后，行持续有创动脉血压监测下，中心静脉采自体血，并行 ANH，在术中出血较多的时段行 CH 以减少术中出血。手术重大步骤完成，出血基本控制后行自体血回输。术中密切监测生命体征，于采血完毕（T1）、回输自体血前（T2）、回输自体血后（T3）分别进行血常规和凝血功能检测，术中血红蛋白（Hb）＜ 70 g/L 回输自体血，术后Hb ＞ 90 g/L 不输异体血。对照组按常规方法处理。 结果 ANH＋CH 组实施期间患者血流动力学基本维持平稳。所有患者采血量（408.3±142.1）mL，出血量（705.4±586.8）mL，出血量和对照组比较明显减少，和对照组患者比较节约血量（549.2±250.2）mL，术后随访未见脏器功能损害等相关并发症，ANH＋CH 组以术前（T0）为基础值，凝血酶原时间（PT）、血细胞比容（Hct）、Hb、纤维蛋白原（FIB）、国际标准化比率（INR）在 T1、T2有显著差异有统计学意义（P ＜ 0.05），但以上各项指标的平均值都在可接受的不影响凝血功能的范围内；回输自体血前后 PT、活化部分凝血活酶时间、血小板、Hct、Hb、FIB、INR 差异有统计学意义（P ＜ 0.05）。两组术后感染、伤口不愈合发生率和住院时间差异有统计学意义（P ＞ 0.05）。结论 ANH 采自体血回输联合 CH 可明显减少异体输血的几率与输血量，适度的血液稀释对患者凝血功能无影响。

Objective To observe the effect of acute normovolemic hemodilution（ANH） with autologous blood transfusion（ABT） and controlled hypotension（CH） during surgery on allogeneic blood transfusion and blood coagulation function.Methods Sixty patients in our hospital from February 2012 to January 2014 were chosen as our study subjects.They underwent surgeries of grade HI to IV,and the estimated amount of bleeding during surgery was more than 400 mL.The patients were randomized into group A（ANH＋CH group） and group B（control group）,with 30 in each.Patients in group A were first administered a standard endotracheal general anesthesia.Then an invasive arterial blood pressure monitoring was performed and the central venous blood was taken.ANH was implemented,and CH was applied to reduce bleeding.When the procedure was almost completed,ABT was implemented.The value of hematocrit,hemoglobin,platelet,prothrombin time（PT）,activated partial thranboplastin time（APTT）,fibrinogen,international normalized ratio（INR）,heart rate,mean arterial pressure and central venous pressure were measured and recorded at the end of blood volume collection（T_1）,and before ABT（T_2） and after ABT（T_3）.When hemoglobin was lower than 70 g/L during the surgery,ABT was implemented.After surgery,no allogeneic blood transfusion was performed if hemoglobin was higher than 90 g/L.Patients in group B received routine treatment.Results Patients＇ hemodynamics maintained relatively stable during ANH＋ABT＋CH.Blood volume collected from patients was（408.3 ±142.1） mL;blood loss volume was（705.4±586.8） mL.Compared with group B,the amount of bleeding was significantly lower,and it was reduced by（549.2±250.2） mL.No organ damage was found.For group A,compared with those values at T_0,PT,hematocrit,hemoglobin,fibrinogen,and INR were significantly different at T_1 and T_2（P〈0.05）,but the average value was within the acceptable range which did not affect the blood coagulation function.PT,APTT,platelet,hematocrit,hemoglobin,fibrinogen,and INR were significantly different before and after autologous blood transfusion（P〈0.05）.Postoperative infection and non-healing wounds rate was not significantly different between the two groups（P〉0.05）.Conclusions This technique of acute normovolemic hemodilution with autologous blood transfusion and controlled hypotension is a useful,efficient and cost-effective blood conservation strategy.Moderate hemodilution has no influence on blood coagulation function in patients.