不同血液稀释法对老年肝癌手术患者凝血及肝脏功能的影响

Effects of different hemodilution on hepatorenal coagulation and liver function of eldly patients underwent hepatectomy

目的:观察急性等容血液稀释(ANH)和术前急性高容血液稀释(AHH)用于老年肝癌患者肝脏肿瘤切除术时对围术期血常规、凝血及肝脏功能的影响。方法:选择全麻下行肝脏肿瘤切除术老年患者45例(ASAⅡ级,年龄60~70岁),随机分为实验组ANH组(A组,n=15)、AHH组(B组,n=15)和对照组(C组,n=15)。A、B组患者分别在麻醉诱导后实施ANH和AHH,C组常规补液输血。观察病人在麻醉诱导前(T1)、血液稀释后30 min(T2)、术毕(T3)和术后24 h(T4)的血常规、凝血和肝脏功能指标的变化。结果:A组术前平均采血量为(740.00±134.99)m L;三组患者围术期出血量相近(P>0.05),A和B组术中分别有3例需输入异体血(20%),C组术中有8例需输入异体血(53.3%),A组和B组异体血需求量比C组明显减少(P<0.01);A和B组患者血红蛋白(Hb)、红细胞压积(Hct)在血液稀释后各时点与T1比较明显降低(P<0.01),与C组比较差异有统计学意义(P<0.05);与T1比较,三组的总蛋白(TP)、白蛋白(ALB)在T2后逐渐降低,组间比较差异有统计学意义(P<0.05);三组谷丙转氨酶(ALT)、谷草转氨酶(AST)在T2以后逐步升高(P<0.05),在T3、T4时点C组显著高于A组(P<0.05);A组在ANH后血浆凝血酶原时间(PT)、活化部分凝血活酶时间(APTT)值与术前比较明显延长,但仍在正常范围以内,回输自体血后指标得到一定改善;三组血浆凝血酶时间(TT)、D-二聚体(D-D)值水平各时点在组内及组间比较差异无统计学意义。结论:ANH及AHH用于老年肝癌切除手术进行血液保护对血常规、凝血和肝脏功能无明显影响,可明显减少异体输血量。

AIM： To observe the effects of preoperative acute normal volemic hemodilution（ ANH）and acute hypervolemic hemodilution（ AHH） on coagulation and liver function in the elderly patients undergoing hepatic carcinectomy. METHODS：Forty-five ASA Ⅱ liver cancer patients（ sixty to seventy years old） undergoing scheduled elective hepatic carcinectomy were randomly divided into ANH group（ group A,n = 15）,AHH group（ group B,n= 15） and the control group（ group C,n = 15）.After tracheal intubation,ANH was performed by letting blood from the jugular vein at the rate of 200-300 m L/10 min and infusing the same volume Voluven（ 130/0. 4） in group A,AHH was performed by infusing 15-20 m L/kg Voluven（ 130/0. 4） at a rate of 30 m L/min in group B,and group C were infused lactated Ringer ＇s solution routinely. Blood routine（ Hb,Hct）,liver function（ TP,ALB,AST,ALT）and coagulation function（ PT, APTT, TT, DD）were observed and compared before anesthesia（ T1）,30 minutes after ANH/AHH（ T2）,end of operation（ T3） and 24 hours after operation（ T4） in group A and B,and the corresponding time in group C. RESULTS： The blood loss volume was similar in the three groups during operations. There was significant difference in the allogeneic blood transfusions between both of the hemodilution groups and the control group（ P〈0. 05）. Compared with T1,the Hb and Hct decreased significantly after hemodilution in group A and B. The plasma protein also significantly decreased after ANH and AHH in group A and B as compared with T1. ALT,AST in each group increased significantly during operation（ P 0. 05）,in T3 and T4 there was significant difference between the group A and C. PT and APTT in group A and B after hemodilution were significantly prolonged（ P 0. 05）,but none of them shifted outside the normal range. No significant changes were found in D-dimer and TT in group A and B. CONCLUSION： ANH or AHH is relatively safe during hepatic carcinectomy for elderly liver cancer patients without cardiac and pulmonary disease. ANH or AHH with 6% hydroxyethyl starch could be well applied to the elderly patients and also decrease allogeneic blood transfusions,with no apparently impact on the blood routine,liver and coagulation function.