人工胶体预充对5~8 kg先天性心脏病患儿体外循环术后凝血及肾功能的影响

Effect of artificial colloid priming on blood coagulation and renal function after undergoing cardiopulmonary bypass in 5-8 kg pediatric patients with congenital heart disease

目的观察使用人工胶体预充对体外循环(ECC)下行简单先天性心脏病(CHD)外科矫治手术的婴幼儿围手术期凝血功能及肾功能的影响.方法选择泰达国际心血管病医院2016年1月至2020年12月收治的年龄6个月~2岁、体质量5~8 kg且首次在ECC下行CHD外科矫治手术的患儿60例,按照应用预充液的不同分为血浆组、琥珀酰明胶组(MJ组)和羟乙基淀粉组(QYJ组),每组20例.分别在患儿麻醉诱导后即刻(T0)和出手术室前(T1)采用血栓弹力图(TEG)进行凝血功能检测,观察患儿凝血反应时间(R值)、血块生成时间(K值)、血块生成率(α角)、最大宽度值(MA值)和凝血综合指数(CI值),并检测患儿T0、T1时刻肾功能指标〔包括血尿素氮(BUN)、血肌酐(SCr)〕.记录患儿术前一般资料、ECC时间、主动脉阻断(ACC)时间、返回重症监护病房(ICU)后1、2、4 h的胸腔引流量和围手术期用血量.结果①3组患儿的性别、月龄、体质量、术前血红蛋白(Hb)、血小板计数(PLT)、BUN、SCr以及ECC时间、ACC时间、术前TEG各参数比较差异均无统计学意义.②与T0比较,3组患儿T1时刻TEG显示R值、K值均明显延长,α角、MA值明显减小〔血浆组:R值(min)为12.9±6.7比8.6±4.5,K值(min)为6.3±3.8比2.1±1.2,α角(°)为44.8±16.2比56.6±12.6,MA值(mm)为45.9±12.1比56.1±8.2;MJ组:R值(min)为16.7±10.2比11.7±3.7,K值(min)为9.5±5.2比3.9±2.3,α角(°)为26.5±14.7比48.0±14.0,MA值(mm)为35.8±6.0比48.1±12.5;QYJ组:R值(min)为11.2±1.8比9.4±1.6,K值(min)为4.4±1.9比3.7±2.5,α角(°)为0.8±13.3比46.7±13.4,MA值(mm)为41.6±5.1比50.1±10.1;均P<0.05〕.与血浆组比较,T0和T1时刻MJ组和QYJ组R值、K值、α角和MA值比较差异均无统计学意义;但T1时刻MJ组和QYJ组的PLT水平均较血浆组明显降低(×109/L:145.6±18.1、143.3±20.2比168.5±23.4,均P<0.05).③MJ组和QYJ组患儿返回ICU后1、2、4 h胸腔引流量虽高于血浆组,但差异无统计学意义.3组患儿围手术期悬浮红细胞用量比较差异均无统计学意义;血浆组使用血浆平均量为(156.4±54.7)mL,使用人工胶体两组患儿未使用血浆.④MJ组和QYJ组T0和T1时刻BUN、SCr水平与血浆组比较差异均无统计学意义.结论人工胶体有导致患者术后PLT水平降低的趋势,但未增加围手术期凝血功能障碍及肾损伤的风险,同时可减少血浆用量,对5~8 kg的简单CHD患儿术中使用是安全的.

Objective To observe the effect of artificial colloid priming on peri-operative blood coagulation and renal function in infants after undergoing simple congenital heart disease(CHD)correction surgery under extracorporeal circulation(ECC).Methods Sixty infants,aged 6 months to 2 years old and with body weight of 5-8 kg,who were admitted to TEDA International Cardiovascular Hospital from January 2016 to December 2020 and received simple CHD correction operation under ECC for the first time were selected as the research objects,and according to the application of priming solution,they were divided into 3 groups:plasma group,succinyl gelatin injection group(MJ group)and hydroxyethyl starch group(QYJ group)according to the different beforehand filled liquids,with 20 cases in each group.The thromboelastograms(TEG)were performed immediately after anesthesia induction(T0)and before leaving the operation room(T1)for detecting blood coagulation function indexes of each group,respectively.The coagulation reaction time(R value),clot formation time(K value),clot formation rate(αangle),maximum width(MA)value and coagulation comprehensive index(CI)were observed,and the renal function indexes[blood urea nitrogen(BUN),serum creatinine(SCr)]were detected at T0 and T1.The preoperative basic data of the infants,ECC time,aortic cross clamp(ACC)time,the situations of chest drainage volume and peri-operative blood consumption amount at 1,2 and 4 hours after returning back into the intensive care unit(ICU)were recorded.Results①The comparisons of infants'gender,body weight,age of months,preoperative hemoglobin(Hb),blood platelet(PLT),BUN,SCr,ECC time,ACC time and preoperative TEG various parameters among the 3 groups had no statistical significant differences.②Compared to T0,the TEG of the three groups at T1 showed prolonged R value,K value,and decreasedαangle,MA value,and the differences among the 3 groups were statistically significant[plasma group:R value(minutes)was 12.9±6.7 vs.8.6±4.5,K value(minutes)was 6.3±3.8 vs.2.1±1.2,αangel(°)was 44.8±16.2 vs.56.6±12.6,MA value(mm)was 45.9±12.1 vs.56.1±8.2;MJ group:R value(minutes)was 16.7±10.2 vs.11.7±3.7,K value(minutes)was 9.5±5.2 vs.3.9±2.3,αangel(°)was 26.5±14.7 vs.48.0±14.0,MA value(mm)was 35.8±6.0 vs.48.1±12.5;QYJ group:R value(minutes)was 11.2±1.8 vs.9.4±1.6,K value(minutes)was 4.4±1.9 vs.3.7±2.5,αangel(°)was 40.8±13.3 vs.46.7±13.4,MA value(mm)was 41.6±5.1 vs.50.1±10.1;all P<0.05].Compared to the plasma group,there were no significant differences in the R value,K value,αangle,MA values of MJ group and QYJ group at T0 and T1,but the PLT levels in MJ group and QYJ group were significantly decreased at T1(×109/L:145.6±18.1,143.3±20.2 vs.168.5±23.4,both P<0.05).③Compared to the plasma group,the average volumes of chest drainage fluid at 1,2 and 4 hours after returning to ICU in MJ group and QYJ group were higher,but the differences were not statistically significant.There were no statistical significant differences in the peri-operative amounts of transfusion of suspended red blood cells among the three groups.The average amount of plasma used in the plasma group was(156.4±54.7)mL,while no plasma was used in the MJ group and QYJ group.④Compared to the plasma group,the levels of SCr,BUN at T0 and T1 in the MJ group and QYJ group had no statistical significant differences.Conclusion Artificial colloid may lead to a tendency of reducing the number of platelets after surgery,but it does not increase the risks of peri-operative coagulation dysfunction and renal injury.Meanwhile,using the artificial colloid can substitute plasma,so the application of plasma is decreased,and the colloid can be safely used in 5-8 kg infants with simple CHD.