右美托咪定对胃癌根治术后凝血功能的影响

Effect of dexmedetomidine on blood coagulation function following radical gastrectomy

目的探讨右美托咪定对胃癌根治术患者术后凝血功能的影响。方法选择拟行开腹胃癌根治术的患者60例,年龄51~70岁,体重53~75kg,ASAⅠ或Ⅱ级,随机分为右美托咪定组(D组)和对照组(C组),D组在麻醉诱导前10 min泵注右美托咪定0.5μg/kg后以0.5μg·kg^(-1)·h^(-1)的速率维持至关腹,C组给予生理盐水。手术在丙泊酚和瑞芬太尼全凭静脉麻醉下完成,术中采取保温措施,并且不使用人工胶体和肝素冲洗液。术后芬太尼自控静脉镇痛,维持视觉模拟评分≤3分。分别在泵注右美托咪定或生理盐水前(麻醉诱导前)和术后3h采集血液标本,行血常规检测红细胞压积和血小板计数,常规凝血功能检测凝血酶原时间(prothrombin time,PT)、活化部分凝血活酶时间(activated partial thromboplastin time,APTT)、血浆纤维蛋白(原)降解产物(fibrin/fibrinogen degradation product,FDP)含量、血浆纤维蛋白原浓度和抗凝血酶Ⅲ活性测定,并行血栓弹力图(thromboelastography,TEG)检测凝血因子反应时间(R)、纤维蛋白原反应时间(K、α角度)和最大幅度(MA)。结果与麻醉诱导前比较,两组术后3h体温和红细胞压积均明显降低(P<0.01);两组术后3h抗凝血酶Ⅲ活性均明显降低,FDP含量均明显增加(P<0.01);术后3hD组R时间明显缩短、MA值明显增加(P<0.05),K时间和α角度麻醉诱导前和术后3h差异无统计学意义;术后3hC组R和K时间明显缩短,α角度和MA值明显增大(P<0.01)。两组麻醉诱导前和术后3h血小板计数、PT、APTT和血浆纤维蛋白原浓度差异无统计学意义。两组麻醉诱导前血浆抗凝血酶Ⅲ活性和FDP含量差异无统计学意义;两组麻醉诱导前TEG各监测指标差异无统计学意义,D组术中丙泊酚和瑞芬太尼的用量明显少于C组(P<0.05);术后3hD组抗凝血酶Ⅲ活性明显高于C组(P<0.01),FDP含量明显低于C组(P<0.05);术后3hD组R时间明显长于C组、MA值明显低于C组(P<0.05),两组术后3hK时间和α角度差异无统计学意义。两组麻醉诱导前和术后3h体温和红细胞压积差异无统计学意义,两组麻醉诱导前和术后3h血小板计数、PT、APTT和血浆纤维蛋白原浓度差异无统计学意义。结论全身麻醉下胃癌根治术中应用右美托咪定,可抑制R时间缩短和MA值增大,同时抑制血浆抗凝血酶Ⅲ活性降低和FDP含量升高,从而改善术后凝血状态。

Objective To explore the effect of dexmedetomidine on blood coagulation following radical gastrectomy.Methods ASA Ⅰ orⅡ patients aged 51-70 years weighing 53-75 kg scheduled for radical gastrectomy were randomly allocated to two groups：dexmedetomidine group（group D）and control group（group C）.Dexmedetomidine 0.5μg/kg was intravenously infused over 10 minutes before anesthesia induction,followed by a rate of 0.5μg·kg-1·h-1 until peritoneal closure in group D and volume-matched normal saline was administrated in group C.Radical gastrectomy was performed under total intravenous anesthesia with propofol and remifentanil.A series of warming measures were implemented and artificial colloid and heparin flushing fluid were not used.Postoperative patient-controlled intravenous analgesia was performed to maintain visual analogue scale≤3.The blood samples were collected for TEG and standard coagulation monitoring before dexmedetomidine and saline administration and 3 hafter surgery.Results The temperature and hematocrit in the postoperative period were significantly less than the preoperative period in two groups（P〈0.01）.In both groups,the activity of plasma antithrombin Ⅲ was significantly decreased and the concentration of plasma FDP was significantly increased in the postoperative period when compared with the preoperative period（P〈0.01）.In group D,the R time was significantly shortened and MA value was significantly increased in the postoperative period when compared with the preoperative period（P〈0.05）and there were no significant differences in the K time andαangle between the preoperative and postoperative period.In group C,the R and K time were significantly shortened and the value for MA andαangle were significantly increased in the postoperative period compared with the preoperative period（P〈0.01）.The platelet counts,PT,APTT,and plasma fibrinogen concentration were comparable between the preoperative and postoperative period in both groups.The requirements of propofol and remifentanil in group D were significantly less than group C（P〈0.05）.In the preoperative period,the plasma antithrombinⅢ activity,FDP concentration,and the values for all TEG variables were similar in both groups.In the postoperative period,the value for MA and the concentration of plasma FDP in group D were less than that in group C and the value for R and the activity of plasma AT Ⅲin group D were more than group C（P〈0.05 or P〈0.01）and there were no significant differences in the K time andαangle in both groups.There were no significant differences in the temperature,hematocrit,platelet counts,PT,APTT,and plasma fibrinogen concentration in the preoperative and postoperative periods between the two study groups.Conclusion Adjunctive dexmedetomidine in general anesthesia could inhibit the decrease of R time and raise of the value for MA,inhibit the decrease of plasma antithrombin Ⅲ activity and raise of FDP concentration,which indicated that dexmedetomidine can improve blood coagulation state after radical gastrectomy.