纯晶体预充液对心脏手术凝血功能的影响

Influence of crystalloid priming solution on coagulation function in cardiac surgery

目的探讨心脏手术体外循环中使用纯晶体预充液与晶体液混合胶体预充液对患者围手术期凝血功能的影响。方法体外循环下行心脏手术患者90例,其中体外循环预充液采用复方电解质注射液者30例为纯晶体组,采用复方电解质注射液+白蛋白者30例为晶体+白蛋白组,采用复方电解质注射液+琥珀酰明胶者30例为晶体+琥珀酰明胶组;比较3组术前NYHA心功能分级、血红蛋白、活化部分凝血活酶时间、纤维蛋白原水平等临床资料;比较3组手术类型、体外循环时间,术中超滤量、尿量,术后24 h尿量、胸腔引流量及体外循环不良事件发生率等临床资料;比较3组患者转机前(T_(1))、鱼精蛋白中和后20 min(T_(2))、入ICU 6 h(T_(3))时活化部分凝血活酶时间、纤维蛋白原水平及凝血反应时间R值、血液凝固时间K值、最大振幅MA值等凝血功能指标。结果纯晶体组术中超滤量[(3445±1036)mL]、术中尿量[(2523±1237)mL]、术后24 h尿量[(2528.5±235.6)mL]均多于晶体+白蛋白组[(2914±975)、(1621±1092)、(1858.3±288.8)mL]、晶体+琥珀酰明胶组[(2310±933)、(1393±1011)、(2025.4±355.7)mL](P<0.05),晶体+白蛋白组与晶体+琥珀酰明胶组比较差异无统计学意义(P>0.05);3组手术类型、体外循环时间、主动脉阻断时间、术后呼吸机辅助时间、ICU治疗时间、住院时间,术中体外循环液体实入量,术中及术后24 h红细胞用量、血浆用量、血小板用量、冷沉淀用量,术后24 h胸腔引流量比较差异均无统计学意义(P>0.05)。3组T_(1)、T_(2)、T_(3)时活化部分凝血活酶时间、血小板计数、血红蛋白、纤维蛋白原水平、凝血反应时间R值及T_(1)、T_(3)时血液凝固时间K值、最大振幅MA值比较差异均无统计学意义(P>0.05)。3组T_(2)时活化部分凝血活酶时间长于T_(1)和T_(3)时(P<0.05),纤维蛋白原水平低于T_(1)和T_(3)时(P<0.05),3组T_(1)与T_(3)时活化部分凝血活酶时间、纤维蛋白原水平比较差异均无统计学意义(P>0.05);3组T_(1)时血红蛋白水平、血小板计数均高于T_(2)和T_(3)时(P<0.05),T_(2)与T_(3)时比较差异均无统计学意义(P>0.05)。3组T_(2)时凝血反应时间R值、血液凝固时间K值均大于T_(1)、T_(3)时(P<0.05),T_(1)与T_(3)时比较差异无统计学意义(P>0.05);纯晶体组T_(2)时最大振幅MA值小于T_(1)、T_(3)时(P<0.05),T_(1)与T_(3)时比较差异无统计学意义(P>0.05),晶体+白蛋白组、晶体+琥珀酰明胶组T_(1)、T_(2)、T_(3)时最大振幅MA值比较差异均无统计学意义(P>0.05)。3组二次开胸止血、二次插管、感觉运动功能障碍、切口愈合不良、死亡/自动出院发生率比较差异均无统计学意义(P>0.05)。结论纯晶体预充液可增加行体外循环心脏手术患者围手术期尿量和超滤量,未影响患者围手术期凝血功能。

Objective To investigate the influence of crystalloid solution versus crystalloid mixed with succinylated gelatin solution on perioperative coagulation function during cardiopulmonary bypass(CPB)in cardiac surgery.Methods In 90patients receiving cardiac surgery under CPB,30patients used multiple electrolytes injection as priming solution(crystalloid group),30patients used multiple electrolytes injection mixed with human serum albumin(crystalloid+albumin group),and 30 patients used multiple electrolytes injection mixed with succinylated gelatin solution(crystalloid+succinylated gelatin group).The preoperative NYHA functional classification,hemoglobin,activated partial thrombin time and fibrinogen were compared among three groups.The type of surgery,CPB time,intraoperative ultrafiltration,urine volume,postoperative 24-h urine volume,chest drainage volume and adverse events of CPB were also compared among three groups.The activated partial thrombin time,fibrinogen,coagulation reaction time R value,coagulation time K value,and time maximum amplitude were compared among three groups before CPB(T_(1)),20min after protamine neutralization(T_(2)),and 6hafter entering ICU(T_(3)).Results The intraoperative ultrafiltration volume,intraoperative urine volume and postoperative 24-h urine volume were larger in crystalloid group[(3445±1036),(2523±1237),(2528.5±235.6)mL]than those in crystalloid+albumin group[(2914±975),(1621±1092),(1858.3±288.8)mL]and crystalloid+succinylated gelatin group[(2310±933),(1393±1011),(2025.4±355.7)mL](P<0.05),and showed no significant differences between crystalloid+albumin group and crystalloid+succinylated gelatin group(P>0.05).There were no significant differences in the operation type,CPB time,aorta clamp time,postoperative mechanical ventilation time,length of ICU stay,length of hospital stay,intraoperative CPB fluid infusion volume,intraoperative and postoperative 24-h red blood infusion,plasma consumption,platelet consumption and cryoprecipitate consumption,as well as postoperative 24-h chest drainage volume among three groups(P>0.05).The activated partial thrombin time,platelet count,hemoglobin,fibrinogen and coagulation reaction time R value showed no significant differences among three groups at T_(1),T_(2)and T_(3),respectively(P>0.05).The coagulation time K values and maximum amplitude values at T_(1)and T_(3)showed no significant differences among three groups(P>0.05).The activated partial thrombin time was longer at T_(2)than that at T_(1)and T_(3)in three groups,and the level of fibrinogen was lower at T_(2)than that at T_(1)and T_(3)(P<0.05),which showed no significant differences between T_(1)and T_(3)(P>0.05).The level of hemoglobin and platelet count were higher at T_(1)than those at T_(2)and T_(3)in three groups(P<0.05),and showed no significant differences between T_(2)and T_(3)(P>0.05).The coagulation reaction time R value and coagulation time K value were larger at T_(2)than those at T_(1)and T_(3)in three groups(P<0.05),and showed no significant differences between T_(1)and T_(3)(P>0.05).The maximum amplitude value was smaller at T_(2) than that at T_(1) and T_(3) in crystalloid group(P<0.05),and showed no significant difference between T_(1)and T_(3)(P>0.05).There were no significant difference in the maximum amplitude values at T_(1),T_(2)and T_(3) between crystalloid+albumin group and crystalloid+succinylated gelatin group(P>0.05).There were no significant differences in the incidences of secondary thoracotomy hemostasis,secondary intubation,sensorimotor dysfunction,wound healing disorder and death/automatic discharge among three groups(P>0.05).Conclusion Crystalloid priming solution can increase perioperative urine volume and ultrafiltration volume,and does not affect the perioperative coagulation function.