急性等容血液稀释联合控制性低中心静脉压在肝癌手术中的应用

Acute Isovolumic Hemodilution Combined with Low Central Venous Pressure in Liver Cancer Surgery

目的探讨急性等容血液稀释(acute normovolemic hemodilution,ANH)联合控制性低中心静脉压(controlled low central venous pressure,CLCVP)技术在肝癌切除手术中的节血效果及安全性。方法方便选择玉林市红十字会医院2014年7月—2017年12月共120例ASAⅠ~Ⅱ级拟在全麻下行肝癌切除手术患者,随机分为ANH联合CLCVP组(Ⅰ组)、CLCVP组(Ⅱ组)和常规手术对照组(Ⅲ组)3组,每组40例。Ⅰ组患者全麻诱导后先行急性等容血液稀释(ANH),然后行低中心静脉压(LCVP)控制,在肝脏实质完全离断前两组(Ⅰ组、Ⅱ组)患者中心静脉压(CVP)控制在3~5 cm H_2O,肝实质切除后将CVP恢复到正常(6~12 cm H_2O);Ⅱ组仅行CLCVP;Ⅲ组患者常规麻醉,不行ANH或CLCVP,在肝实质完全离断前、后维持CVP在6~12 cm H_2O。观察3组患者不同时点Hb、Hct及血乳酸值指标的变化;手术结束时计算患者总失血量、异体输血量、异体输血例数和术中尿量。结果Ⅰ组总出血量(472±129)mL、异体输血量(246±105)mL和异体输血例数9例,Ⅱ组总出血量(517±116)mL、异体输血量(350±163)mL和异体输血例数23例,Ⅲ组总出血量(882±263)mL、异体输血量(676±283)mL和异体输血例数31例,与Ⅲ组比较,Ⅰ组和Ⅱ组出血量、异体输血量和输血例数明显减少,差异有统计学意义(P<0.05),与Ⅱ组比较,Ⅰ组异体输血量和输血例数减少,差异有统计学意义(P<0.05);3组患者术中尿量比较差异无统计学意义(P>0.05);Ⅰ组血液稀释后Hct值(T1)明显下降,组内比较差异有统计学意义(P<0.01),Ⅱ组和Ⅲ组组间比较差异无统计学意义(P>0.05);3组患者各时点血乳酸指标均在正常范围内,组间比较差异无统计学意义(P>0.05),说明对器官灌注及组织氧供无明显影响。结论 ANH联合CLCVP及CLCVP两项技术均可减少术中出血量和异体输血量,而ANH联合CLCVP技术节血效果更为显著,且对器官灌注及组织氧供无明显影响,可安全应用于肝癌切除手术中。

Objective To investigate the effect and safety of acute normovolemic hemodilution(ANH)combined with controlled low central venous pressure(CLCVP)in liver cancer resection.Methods From July 2014 to December 2017 in Yulin City Red Cross Hospital,a total of 120 ASA I-II patients scheduled to undergo hepatic resection under general anesthesia were randomized to ANH combined CLCVP(Group I)and CLCVP(Group II)and conventional surgical control group(Group III)three groups of 40 patients each.In group I,patients received acute isovolumic hemodilution(ANH)after induction of general anesthesia,followed by low central venous pressure(LCVP)control,and central venous pressure(CVP)in both groups(group I and II before complete hepatic parenchyma separation)controlled at 3 to 5 cmH2O,CVP recovered to normal after hepatic parenchymal resection(6 to 12 cmH2O).Group II received only CLCVP;Group III patients underwent rou-tine anesthesia without ANH or CLCVP before and after complete dissection of hepatic parenchyma maintain CVP at 6-12 cmH2O.Observe the changes of Hb,Hct and blood lactate at different time points in the three groups of patients;calculate total blood loss,allogeneic blood transfusion,allogeneic blood transfusions,and intraoperative urine volume at the end of surgery.Results Total blood loss in group I was(472±129)mL,allogeneic blood transfusion volume was(246±105)mL and allogeneic blood transfusions were 9 cases,group II total blood loss was(517±116)mL,and allogeneic blood transfusion volume was(350±163)mL in 23 cases of allogeneic blood transfusions,total blood loss(882±263)mL,group III blood transfusion volume(676±283)mL,and allogeneic blood transfusions in 31 cases,compared with group III,group I and group II blood loss Allogeneic blood transfusions and transfusions were significantly reduced,the different was statistically significant(P<0.05).Compared with group II,allogeneic blood transfusions and transfusions were reduced in group I,the different was statistically significant(P<0.05);intraoperative urine volume was not statistically significant in the three groups(P>0.05);The Hct value(T1)decreased significantly in Group I after hemodilution,and there was a statistically significant difference between the two groups(P<0.01).There was no significant difference between Group II and Group III(P>0.05).The blood lactic acid indicators of all three groups were within the normal range at each time point.There was no significant difference between the groups(P>0.05),indicating that there was no significant effect on organ perfusion and tissue oxygen supply.Conclusion Both ANH combined with CLCVP and CLCVP can reduce intraoperative blood loss and allogeneic blood transfusion,while ANH combined with CLCVP technique is more effective in reducing blood volume,and has no significant effect on organ perfusion and tissue oxygen supply,and can be safely applied to liver cancer excision surgery.