急性等容血液稀释联合术中血液回收对脊柱骨折患者术中血液保护的效果

Effect of acute normovolemic hemodilution combined with intraoperative blood salvage in blood conservation during surgery for spine fracture

目的探讨急性等容血液稀释(ANH)联合术中血液回收(IBS)对脊柱骨折手术患者术中血液保护的效果。方法采用回顾性病例对照研究分析2016年1月至2019年10月成都市第一人民医院收治的111例胸腰椎骨折患者临床资料,其中男61例,女50例;年龄27~64岁[(44.6±8.3)岁]。损伤节段:T11~L1 30例,T10~L1 45例,T11~L2 30例,L1~L3 6例。患者均行后路减压椎弓根螺钉固定术治疗。37例应用ANH进行血液保护(A组),37例应用IBS进行血液保护(B组),37例应用ANH联合IBS进行血液保护(C组)。记录A组和C组放血前(T0)、放血后10 min(T1)、自体血回输前(T2)、回输血结束后30 min(T3)4个时相点平均动脉压(MAP)、中心静脉压(CVP)、心率(HR)、血红蛋白(Hb)、红细胞压积(Hct)、凝血酶原时间(PT)、活化部分凝血活酶时间(APTT);B组于麻醉诱导后10 min(T0)、手术开始前(T1)、自体血回输前(T2)及回输血结束30 min后(T3)记录检测相同指标。比较三组术中失血量、异体红细胞输注量及输注率、新鲜冰冻血浆输注量及输注率、术后感染发生率及住院时间。结果 T0时,三组MAP、CVP、HR差异无统计学意义(P>0.05);T1时,A、C组MAP较B组降低(P<0.05);T2时,三组CVP较T0时降低(P<0.05)。T1和T2时,A、C组Hb、Hct较B组降低(P<0.05);T2和T3时,三组Hb、Hct较T0时降低(P<0.05)。T2和T3时,三组PT、AAPT较T0时延长(P<0.05),尚在正常范围内;T3时,A、C组PT、APTT低于B组(P<0.05)。三组术中失血量差异均无统计学意义[(935.4±226.8)ml ∶(1 037.8±270.1)ml ∶(1 003.5±198.7)ml](P>0.05)。C组红细胞输注量为(275.0±95.7)ml,显著低于A组[(450.0±119.5)ml]和B组[(487.5±127.5)ml](P<0.05);三组红细胞输注率差异均无统计学意义[19%(7/37) ∶22%(8/37) ∶11%(4/37)](P>0.05);三组新鲜冰冻血浆输注量[(233.3±60.6)ml ∶(282.9±81.0)ml ∶(216.7±76.4)ml]及输注率[14%(5/77) ∶19%(7/37) ∶8%(3/37)]差异均无统计学意义(P>0.05)。三组术后感染发生率[5%(2/37) ∶8%(3/37) ∶8%(3/37)]及住院时间[(10.9±2.7)d ∶(12.0±3.1)d ∶(11.0±2.2)d]差异均无统计学意义(P>0.05)。结论对脊柱骨折手术患者而言,ANH联合IBS可以减少术中异体输血需求,对血流动力学、凝血功能无不良影响,可以安全应用于临床。

Objective To investigate the efficacy of acute normovolemic hemodilution(ANH)combined with intraoperative blood salvage(IBS)in blood-conservation for spinal fracture surgery.Methods A retrospective case-control study was conducted to analyze the clinical data of 111 patients with thoracolumbar fractures admitted to Chengdu First People's Hospital from January 2016 to October 2019.There were 61 males and 50 females,aged 27-64 years[(44.6±8.3)years].In terms of the injured segments,there were 30 patients with T11-L1,45 with T10-L1,30 with T11-L2,and 6 with L1-L3.All patients underwent posterior decompression pedicle screw fixation.Thirty-seven patients received ANH for blood conservation(Group A),37 patients received IBS for blood conservation(Group B),and 37 patients received ANH combined with IBS for blood conservation(Group C).The mean arterial pressure(MAP),central venous pressure(CVP),heart rate(HR),hemoglobin concentration(Hb),hematocrit(Hct),prothrombin time(PT),and activated partial thrombin time(APTT)were recorded in Group A and C before blood drainage(T0),10 minutes after blood drainage(T1),and before(T2)and 30 minutes after(T3)retransfusion.Whereas in Group B the same parameters were measured 10 minutes after anesthesia induction(T0),before surgery(T1),and before(T2)and 30 minutes after(T3)transfusion of autologous blood.Intra-operative blood loss,volume of allogenic red blood cell transfusion,rate of allogenic red blood cell transfusion,volume of fresh frozen plasma transfusion,rate of fresh frozen plasma transfusion,incidence of postoperative infection,and length of hospital stay were recorded and compared among the three groups.Results There were no significant differences in MAP,CVP and HR between the three groups at T0(P>0.05).The levels of MAP in Group A and C were lower than that in Group B at T0(P<0.05).The levels of CVP at T2 in three groups were lower than that at T1(P<0.05).The levels of Hb and Hct in Group A and C were lower than those in Group B at T1-T2(P<0.05).The levels of Hb and Hct at T2-T3 in the three groups were lower than those at T0(P<0.05).The PT and APTT at T2-T3in the three groups were longer than those at T0(P<0.05),but were all within the normal range.The PT and APTT at T3in Group A and C were lower than those in Group B(P<0.05).There was no significant difference in intraoperative blood loss among the Group A,B and C[(935.4±226.8)ml:(1037.8±270.1)ml:(1003.5±198.7)ml](P>0.05).The volume of allogenic red blood cell transfusions in Group C was(275.0±95.7)ml,significantly lower than that in Group A[(450.0±119.5)ml](P<0.05)and Group B[(487.5±127.5)ml](P<0.05).There was no significant difference in the rate of allogenic red blood cell transfusion among Group A,B and C[19%(3/37):22%(8/37):11%(4/37)](P>0.05).There was no significant difference in the volume of fresh frozen plasma transfusion[(233.3±60.6)ml:(282.9±81.0)ml:(216.7±76.4)ml]and rate of fresh frozen plasma transfusion[14%(5/37):19%(7/37):8%(3/37)]among Group A,B and C(P>0.05).Postoperative infection[5%(2/37):8%(3/37):8%(3/37)]and length of hospital stay[(10.9±2.7)days:(12.0±3.l)days:(11.0±2.2)days]showed no significant difference among Group A,B and C(P>0.05).Conclusion For the spinal fracture surgery,ANH combined with IBS can reduce the intraoperative need for allogenic transfusion and have no adverse effects on hemodynamics and coagulation function,which can be safely applied in clinical practice.