骨科脊柱患者术中自体血液回输对血浆胶体渗透压和肺功能的影响

Effects of intra-operative blood transfusion on the plasma colloid osmotic pressure and pulmonary function of patients

目的观察术中不同血液回输量对血浆胶体渗透压(COP)和肺功能的影响。方法选择符合条件的拟在全身麻醉下行骨科脊柱手术的患者,根据术中出血量和自体血液回输量将患者分成3组:自体血液回输量≤250m L(A组)、自体血液回输量251-500 m L(B组)和自体血液回输量>500 m L(C组)。3组患者均采用气管插管全身麻醉和机械通气:潮气量8 m L/kg、呼吸频率(10-18)次/min、吸/呼比为1∶2。术中监测BP、HR、ECG、Sp O2、CVP、PET CO2、动脉血气、COP和气道峰压。术中对创面的所有血液进行回收和肝素抗凝,然后进行洗涤、离心和回输。术中根据患者的血液动力学变化调整液体入量,所有液体按晶体/胶体比1.5∶1的比例分别给予复方氯化钠和6%的羟乙基淀粉130/0.4氯化钠注射液。术中根据血气分析调整呼吸频率、电解质和酸碱平衡。麻醉诱导前(T0)、麻醉后(T1)、切皮前(T2)、血液回输前(T3)、血液回输后15 min(T4)和手术结束后(T5)分别记录患者的血液动力学变化、呼吸参数变化并计算肺的动态顺应性、监测COP、血气变化并计算肺泡-动脉氧分压差(PA-a DO2)和氧合指数(Pa O2/Fi O2)。结果 1)COP的变化:1)组内比较:A组T1、T2、T3、T4、T5各时点和T0相比无显著变化(P>0.05);B组、C组的T1、T2各时点和对应的T0相比无明显变化(P>0.05),B组、C组T3、T4、T5各时点(B/C:20.7±1.9/18.0±1.8、19.0±2.1/17.3±1.8、19.6±2.4/17.1±2.9)和对应的T0(23.0±2.5/23.1±2.1)相比明显下降(P<0.05)。2)组间比较:T0、T1、T2各时点3组间无明显变化(P>0.05);B组T3、T4、T5(20.7±1.9、19.0±2.1、19.6±2.4)各时点较A组(21.6±2.1、21.3±1.9、22.0±2.2)对应各时点明显下降(P<0.05),C组T3、T4、T5(18.0±1.8、17.3±1.8、17.1±2.9)各时点较相应的A组(21.6±2.1、21.3±1.9、22.0±2.2)和B组(20.7±1.9、19.0±2.1、19.6±2.4)均显著下降(P<0.05)。2)PA-a DO2和Pa O2/Fi O2变化:(1)组内比较:A组的T2、T3、T4、T5各时点和T1相比无显著变化(P>0.05);B组的T3、T4、T5(160.8±30.7/335.1±30.6、165.1±31.2/347.0±35.8、158.9±33.7/351.1±36.8)各时点和相应的T1(148.8±23.8/461.0±42.4)相比PA-a DO2显著增加、Pa O2/Fi O2显著降低(P<0.05),C组的T3、T4、T5(240.1±41.5/229.0±26.6、267.9±45.5/249.1±25.5、251.8±40.6/248.1±22.7)各时点和T1(144.7±21.9/473.4±44.6)相比PAa DO2显著增加、Pa O2/Fi O2显著降低(P<0.05)。(2)组间比较:T1、T2各时点3组间无明显变化(P>0.05);B组T3、T4、T5(160.8±30.7/335.1±30.6、165.1±31.2/347.0±35.8、158.9±33.7/351.1±36.8)各时点较A组(139.1±28.5/450.1±46.5、142.1±22.2/458±40.1、146.0±25.3/461.0±44.9)PA-a DO2显著增加、Pa O2/Fi O2显著降低(P<0.05),C组较A组和B组PA-a DO2显著增加、Pa O2/Fi O2显著降低(P<0.05)。3)胸-肺顺应性:(1)组内比较:A组、B组内的T2、T3、T4、T5各时点和T1比较无明显变化(P>0.05);C组的T3、T4、T5(40.2±6.3、39.1±5.0、40.3±6.6)各时点和T1(49.9±9.8)比较显著降低(P<0.05)。(2)组间比较:T1、T2各时点3组间无明显变化(P>0.05),T3、T4、T5各时点B组和A组比较无明显变化(P>0.05),C组T3、T4、T5(40.2±6.3、39.1±5.0、40.3±6.6)各时点较B组(44.3±5.1、44.2±5.9、50.7±7.7)和A组(44.6±5.8、45.0±5.5、53.2±7.9)明显下降(P<0.05)。结论术中失血和血液回收回输量在>250 m L时会明显减低患者的COP,并影响肺的氧合功能;自体血回输>500 m L时不但明显降低患者的COP、肺的氧合功能而且会明显降低肺的顺应性,大量自体血回输时建议同步给予血浆或白蛋白等提高患者的COP。

Objective To observe the volume of intra-operative cell salvage（ ICS） and its corresponding effect on the plasma colloid osmotic pressure（ COP） and pulmonary function of the patient. Methods Patients scheduled for the spinal surgery during general anesthesia were enrolled and divided into 3 groups according to the volumes of blood loss and ICS：Group A（ ICS≤250 m L）,Group B（ ICS 251-500 m L） and Group C（ ICS〉500 m L）. All patients received general anesthesia and mechanical ventilation after intubation（ VT = 8 m L/kg,RR = 10-18/min,I/E = 1 ∶2）. BP,HR,ECG,Sp O2,CVP,PETCO2,blood gas analysis,plasma colloid osmotic pressure（ COP） and the Peak airway pressure were measured and monitored during the surgery. Blood salvage was performed with heparin anti-coagulation and washed,centrifuged and collected using a sterile bag,and then the red blood cells were transfused before the end of surgery. Fluid was infused according to the intra-operative hemodynamics,and the liquids consisted of compound sodium chloride and 6% hyroxyethyl starch 130/0. 4 at the ratio of 1. 5 ∶ 1. Respiration rate,electrolyte and acid-base balance were adjusted based on the blood-gas analysis. The change of hemodynamics,ventilation parameters and COP were measured at the following time points： before anesthesia induction（ T0）,after anesthesia induction（ T1）,before the skin cut（ T2）,before autologous blood transfusion（ T3）,15 min after transfusion（ T4） and the end of surgery（ T5）. Dynamic pulmonary compliance,alveolar arterial blood oxygen difference（ PA-a DO2） and oxygenation index（ Pa O2/Fi O2） were calculated based on the respiration parameters and blood gas analysis.Results 1. COP： Intra-group comparison： For group A,no significant difference was found at any of the time points observed（ P〉0. 05）. For group B and C,COP were significantly decreased at T3,T4,T5（ B/C： 20. 7±1. 9/18. 0±1. 8,19. 0±2. 1/17. 3±1. 8,19. 6±2. 4/17. 1±2. 9）（ P〈0. 05） while no significant difference was seen in T1 and T2（ P〈0. 05） as compared with that at T0（ 23. 0±2. 5/23. 1±2. 1）. Inter-groups comparison： For T0,T1 and T2,no significant difference was found among the 3 groups（ P〉0. 05）. For T3,T4 and T5,the COP values in group B（ 20. 7±1. 9,19. 0±2. 1,19. 6±2. 4）was lower than that in group A（ 21. 6±2. 1,21. 3±1. 9,22. 0±2. 2）,and the COP in group C（ 18. 0± 1. 8,17. 3± 1. 8,17. 1±2. 9） was the lowest compared to the other two（ P〈0. 05,respectively）. 2. PA-a DO2 and Pa O2/Fi O2： Intra-group comparison： For group A,PA-a DO2 and Pa O2/Fi O2 no significant difference was found at any of the time points observed（ P〉0. 05）.For group B（ 160. 8± 30. 7/335. 1 ± 30. 6,165. 1 ± 31. 2/347. 0 ± 35. 8,158. 9 ± 33. 7/351. 1 ± 36. 8） and C（ 240. 1 ± 41. 5/229. 0±26. 6,267. 9±45. 5/249. 1±25. 5,251. 8±40. 6/248. 1±22. 7）,PA-a DO2 was significantly increased at T3,T4,T5（ P〈0. 05,respectively）,while Pa O2/Fi O2 was decreased as compared with that at T1（ 144. 7±21. 9/473. 4±44. 6） respectively（ P〈0. 05,respectively）. Inter-groups comparison： For T1 and T2,no significant difference was confirmed among the 3 groups（ P〈0. 05,respectively）. For T3,T4 and T5,PA-a DO2 was higher while Pa O2/Fi O2 was lower in group B than that in group A（ P〈0. 05,respectively）. In addition,PA-a DO2 in group C was higher than that in group B and A,while Pa O2/Fi O2 was lower compared the other two groups（ P〈0. 05,respectively）. 3. Lung compliance： Intra-group comparison： For group A and B,lung compliance at T2、T3、T4、T5 showed no significant difference when compared with that at T1（ P〉0. 05）.For group C,lung compliance at T2、T3、T4、T5（ 40. 2±6. 3、39. 1±5. 0、40. 3±6. 6） was decreased than that at T1（ 49. 9±9. 8）（ P〈0. 05）. Inter-groups comparison： For T1 and T2,no significant difference was observed among the 3 groups（ P〈0. 05）.For T3,T4 and T5,lung compliance was significantly decreased in group C（ 40. 2±6. 3,39. 1±5. 0,40. 3±6. 6） as compared to group B（ 44. 3±5. 1,44. 2±5. 9,50. 7±7. 7） and A（ 44. 6±5. 8,45. 0±5. 5,53. 2±7. 9）（ P〈0. 05,respectively）. Conclusion Intra-operative blood loss and autologous blood transfusion（〉 250 m L） resulted in the reduction in plasma colloid osmotic pressure and oxygenation capacity. Autologous blood transfusion（〉 500 m L） would further reduce the lung compliance apart from the decreased COP and oxygenation capacity. Massive autologous blood transfusion necessitated the infusion of plasma or albumin simultaneously to increase the plasma colloid osmotic pressure.